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9    GONORRHOEA 
AND  ITS  COMPLICATIONS 

IN  THE   MALE  AND   FEMALE 


Digitized  by  tine  Internet  Arcinive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/gonorrhaitscomplOOwats 


GONORRHCEA 

AND  ITS  COMPLICATIONS 

IN  THE   MALE   &    FEMALE 


BY 

DAVID    WATSON,    M.B.,    CM. 

LECTURER    ON    VENEREAL    DISEASES    TO    THE    UNIVERSITY    OF    GLASGOW 

SURGEON    IN    CHARGE    OF    THE    VENEREAL    DEPARTMENT 

GLASGOW    ROYAL    INFIRMARY 

LATE    SURGEON    GLASGOW    HOSPITAL    FOR    WOMEN 

LATE    DISTRICT    SURGEON    GLASGOW    MATERNITY'    flOSPITAL,  ETC. 


WITH    72    ILLUSTRATIONS    AND    12    PLATES 
9   OF   WHICH    ARE   IN   COLOURS 


NEW    YORK 

PAUL     B.     HOEBER 

69     EAST    59th    STREET 
1915 


All  rights  reserved. 
1 


PREFACE 

In  English  Medical  Literature,  the  subject  of  Gono- 
coccal disease  has  been  treated  with  a  quite  unmerited 
neglect.  The  explanation  is  difficult  to  find.  Gonor- 
rhoea is  one  of  the  common  ailments  ;  its  immediate 
effects,  in  some  cases,  and  its  remote  effects  in  many 
cases,  are  of  serious  import.  I  refrain  from  quoting 
here  any  figures  relative  to  the  prevalence  of  gonor- 
rhoea, as  no  accurate  data  are  available  ;  but  that 
the  incidence  of  the  disease  is  a  high  one  few  will 
dispute.  What  is  insufficiently  realised  in  this  country 
is  the  real  gravity  of  the  infection  ;  the  many  and 
serious  troubles  which  the  future  has  in  store  for  a 
large  proportion  of  those  who  contract  gonorrhoea. 
The  treatment  of  gonorrhoea  is  seldom  adequate 
either  in  the  male  or  female,  and  a  frequent  result 
is  a  chronic  infective  condition  with  its  constant  risks 
of  exacerbations  and  complications,  which,  when  they 
do  occur,  are  only  too  frequently  misinterpreted. 

The  author  of  a  special  treatise  is  open,  with  what- 
ever measure  of  justification,  to  the  charge  of  a 
perhaps  involuntary  tendency  to  exaggerate  the 
importance  of  the  subject  which  he  has  made  his 
own.  Quotations  from  the  works  of  other  specialists 
are  equally  liable  to  suspicion.  More  convincing 
will  be  the  conclusions  of  such  a  careful  writer  as 
Professor  Osier :  "  Gonorrhoea,  one  of  the  most 
widespread  and  serious  of  infectious  diseases,  pre- 
sents many  features  for  consideration.     As  a  cause 


vi  PREFACE 

of  ill-health  and  disability,  the  gonococcus  occupies 
a  position  of  the  very  first  rank  among  its  fellows. 
While  the  local  lesion  is  too  often  thought  to  be 
trifling,  in  its  singular  obstinacy,  in  the  possibilities 
of  permanent  sexual  damage  to  the  individual  him- 
self, and  still  more  in  the  'grisly  troop'  which  may 
follow  in  its  train,  gonorrhoeal  infection  does  not  fall 
very  far  short  of  syphilis  in  importance." 

The  larger  proportion  of  gonorrhoea  practice  is  in 
the  hands  of  prescribing  chemists  and  of  quacks,  and 
for  this  the  medical  profession  cannot  be  held 
blameless.  We  have  looked  somewhat  askance  at 
these  cases  and  have  failed  to  take  the  interest  in  the 
disease  which  it  deserves.  But  the  laboratory  and 
clinical  investigations,  which  have  now  been  com- 
pleted, and  of  which  some  account  is  presented  in 
this  volume,  have  established  the  diagnosis  and 
treatment  of  the  various  manifestations  of  gonococ- 
cal infection  on  a  scientific  basis,  and  brought  them 
within  the  sphere  of  the  educated  practitioner,  where 
they,  in  common  with  all  other  ailments,  rightly 
belong.  The  object  of  this  book  is  to  place  at  the 
disposal  of  the  practitioner  and  the  student  a  review 
of  the  work,  as  I  understand  it,  of  the  many  scientists 
and  clinicians  to  whose  labours  any  merit  that  this 
book  may  possess  is  due.  During  the  past  twelve 
years  I  have  been  fortunately  placed  so  far  as  hospital 
and  laboratory  facilities  are  concerned  and  have  thus 
been  able  to  assimilate  and  corroborate  the  opinions 
expressed  in  the  following  pages. 

With  considerable  regret,  I  have  had  to  omit 
references  to  several  books  and  papers  to  which  I  am 
indebted,  but  the  resulting  condensation  has,  I  hope, 
increased  the  general  as  against  the  special  utility  of 
the  volume. 


PREFACE  vii 

An  excellent  bibliography  will  be  found  in  "Hand- 
buch  der  Geschlechtskrankheiten,"  edited  by  Drs.  Fin- 
ger, Jadassohn,  Ehrmann  and  Grosz,  which  contains, 
by  authoritative  writers,  the  fullest  description  of 
gonococcal  disease.  Oberlaender  and  Kollmann's 
"  Chronic  Gonorrhoea  and  Its  Complications,"  Luys's 
"Treatise  on  Gonorrhoea  and  Its  Complications,"  and 
Norris  on  "  Gonorrhoea  in  Women,"  are  all  books  of  the 
first  importance  on  this  subject. 

I  am  indebted  to  Mr.  H.  W.  Boot  and  to  Mr. 
E.  J.  Burke  for  drawings  of  some  of  my  specimens, 
and  to  the  Matron  of  the  Glasgow  Lock  Hospital  and 
to  Mr.  Anderson  of  the  Glasgow  Royal  Infirmary  for 
photographs  of  cases,  and  also  to  Dr.  W.  Blair  M. 
Martin,  Dr.  Norris,  Dr.  Chetwood,  the  Joint  Committee 
of  Henry  Frowde  and  Hodder  and  Stoughton,  and 
the  pubHshers  of  the  late  Dr.  R.  W.  Taylor's  book 
"  Sexual  Disorders  "  for  liberty  to  use  illustrations. 


David  Watson. 


116  Mains  Street,  Blythswood  Square, 
Glasgow,  July,  1914. 


GONTElNTS 


CHAPTER 

I.     History  of  C4oxorkhcea 


II.     Bacteriology  of  Go^"ORRHCEA 


Discovery  of  the  Gonococcus 
Microscopic  Appearance  of  the  Gonococcus 
Staining  of  Gonococci 
Preparation  of  Smears 

From  the  Male      .... 

From  the  Female .... 
Bacteriology — Of  the  Male  Genital  Tract 

„  Of  the  Female  Genital  Tract 

Bacteriological  Examination  of  Urine     . 
Cultivation  of  the  Gonococcus 


PAGE 
1 


9 
10 
11 
13 
19 


III.     Pathological  Histology  of  Gonococcal  iNFLAaiJviA- 

Tiox       ........      33 


Pathology  of  Acute  Gonorrhoea 
Pathological  Changes  of  Qironic  Urethi'itis 

Soft  and  Hard  Infiltrations     . 

Cystic  Abscesses  .... 

Epithelial  Changes 

IV.     Acute  Gokococcal  Urethritis  ix  the  Male 

Modes  of  Infection        .... 

Venereal       ..... 

Extra-venereal      .... 
Period  of  Incubation    .... 
Gonoccoccus  Invasion  of  the  Male  Urethra 
Anatomy  of  the  Male  Urethra 
Striated  and  Unstriated  Musculatm'e  of  the  Urethra 
The  Sphincters  of  the  Urethra  and  their  Actions 
Distribution  of  the  Gonococcus  in  the  Male  Urethra 


33 
35 
36 
37 
37 

39 

39 
39 
40 
41 
42 
42 
51 
51 
55 


CONTENTS 


CHAPTER 

IV. 


V. 


VI. 


AcTjTE  Gonococcal  Urethritis  in  the  Male — contd 
Acute  Anterior  Gonococcal  Urethritis 
Mucous  Stage      ..... 
Microscopic   Appearance  of   the   Discharge  in  the 

Mucous  Stage  .... 

Purulent  Stage    ..... 
Microscopic   Appearance   of   the  Discharge  in  the 

Purulent  Stage  .... 

Terminal  Stage  ..... 
Microscopic   Appearance   of   the  Discharge   in   the 
Terminal  Stage  ..... 

Subacute  Type  of  Gonococcal  Urethritis 
Hyperacute  Type  of  Gonococcal  Urethritis 
Acute  Posterior  Gonococcal  Urethritis    . 
Terminal  Haematuria  ..... 
Thompson's  Separate  Glass  Test    . 

Treatment  of  Acute  Gonococcal  Urethritis 
General  Treatment       .... 

Diet 

Internal  Treatment  of  Gonorrhoea 
Balsams     ...... 

Urinary  Antiseptics     .... 

Local    Treatment    of    Acute    Gonococcal   Ure 
THRITTS  ...... 

Urethral  Injection  Treatment 
Reagents  emiDloyed  for  Urethral  Injections 
Urethro-vesical  Lavation  (Grand  Lavage) 
Solutions  employed  in  Lavation     . 
Abortive  Treatment     .... 
Abortive  Lavation        .... 
Treatment  by  applying  Heat  to  the  Urethra 
Bier's  Treatment  of  Urethritis 
Soluble  Medicated  Bougies   . 
Treatment  of  Acute  Posterior  Urethritis 


Chronic  Gonococcal  Urethritis 
Definition  .... 
Post-gonorrhoeal  Conditions 
Symptoms  of  Chronic  Urethritis 
Diagnosis  of  Chronic  L^rethritis 
Provocative  Stimulation  of  Latent  Gonococci 
Urinary  Filaments 
Phosphaturia  of  Chronic  L^rethritis 


57 
58 

58 
59 

61 
62 

63 
63 
65 
70 
73 
74 

78 
79 
81 

82 
82 
85 

87 
89 
93 
100 
104 
107 
110 
111 
112 
112 
112 

116 
116 
117 
119 
120 
122 
125 
125 


CONTENTS 


XI 


CHAPTER  PAGE 

VII.     Tbeatment  of  Chronic  Gonococcal  Urethritis  .    127 

Lavation,  Irrigation,  and  Injections        .  .  .    128 

Dilatation  by  Bougies  and  Sounds           .  .  .129 

Different  Scales  for  Measuring  Sounds    .  .  .133 

Dilatation  by  Kollmann's  Dilators           .  .  .138 

Electrolysis 140 

Cauterization      .           .           .           .           .  .  .141 

Incision  of  Abscesses  and  Fibrous  Bands  .  .    143 

Curetting  of  the  Male  Urethra        .           .  .  .144 

Instillations         .           .           .           .           .  .  .144 

Thernio-therapy            .           .           .           .  .  .144 

Ionization             .           .           .           .           .  .  .147 

Medicated  Bougies,  Ointments,  etc.         .  .  .149 


VIII.     The   Urethroscope   in   the   Diagnosis   and   Treat- 
ment of  Chronic  Urethritis  .  .  .151 

History  of  the  Urethroscope  .  .  .  .152 

Externally  lit  Urethroscopes  .  .  .  .154 

Internally  lit  Urethroscopes  ....    155 

Urethroscopes  for  the  Posterior  Urethra  .  .160 

Technique  of  Urethroscopy  .  .  .  .  .162 

The  Appearance  of  the  Normal  Anterior  Urethra 

as  Seen  Through  the  Urethroscope      .  .  .164 

The  Normal  Posterior   Urethra   as   Seen  Through 

the  Urethroscope      .  .  .  .  .  .166 

Diseased  Conditions  of  the  Anterior  Urethra 

AS  Seen  Through  the  Urethroscope   .  .167 

Infiltrations  :   Soft       ......    168 

Hard 169 

Papillomatous  Growths         .  .  .  .  .171 

Fissures      ........    171 

Cysts 171 

Diseased  Conditions  of  the  Posterior  Urethra 

AS  Seen  Through  the  Urethroscope   .  .171 


IX.       NON-GONORRHCEAL    URETHRITIS     (URETHRITIS    SiMPLEX)    173 

Urethritis  Arising  from  Mechanical,   Chemical,   or 


Thermal  Irritation   .... 
Organisms  producing  Urethritis  Simplex 


173 
174 


Xll 


CONTENTS 


CHAPTER  PAGE 

X.     Gonococcal  Balanitis  and  Balano-posthitis  .    177 

Anatomy  of  Glans  and  Prepuce     .  .  .  .177 

Bacteriology  of  Preputial  Sac         ....    178 
Symptoms  of  Acute  Balanitis  with  Phimosis  .  .180 

Symptoms  of  Acute  Balanitis  with  Paraphimosis     .    180 

Treatment 181 

Chronic  Gonococcal  Balanitis    ....   181 


XI. 


XII. 


Gonococcal  Prostatitis  .  .  .  .  .184 

Anatomy  of  the  Prostate       .  .  .  .  .184 

Physiology  of  the  Prostate    .  .  .  .  .187 

The  External  Secretion  of  the  Prostate  .  .  .188 

Method  of  Exaixdning  the  Prostate  .  .  .190 

Classification  of  Gonococcal  Prostatitis  .  .    191 

Acute  Gonococcal  Prostatitis  ....    194 

Secretion  of  the  Infected  Prostate  .  .  .197 

Treatment  of  Acute  Prostatitis         .  .  .   198 

Prostatic  Abscess        .  .  .  .  .  .   199 

Treatment  of  Prostatic  Abscess     ....    203 

Chronic  Prostatitis     ......    205 

Character  of  the  Prostatic  Fluid  in  Chronic  Prostatitis  207 
Sexual  Neiu-asthenia    .  .  .  .  ...    208 

Treatment  of  Chronic  Prostatitis      .  .  .210 

Gonococcal  Vesiculitis  (Spermato-cystitis)    .  .213 

Anatomy  and  Physiology  of  the  Vesiculse  Seminales  213 
Method  of  Examining  Vesiculse  Seminales        .  .    216 

Acute  Vesiculitis  .  .  .  .  .  .217 


XIII. 


Chronic  Vesiculitis 
Massage  of  the  Vesicle 

Gonococcal  Epididymitis 
Incidence  . 
Anatomy  . 
Etiology  . 
Deferenitis 
Pathology  of  Epididymitis 
Symptoms  of  Epididymitis 
Treatment 

Operative  Treatment  . 
Epididymotomy 
Epididymo-vasotomy 
Belfield's  Operation     . 


218 
220 

222 

222 
224 
227 
228 
229 
230 
233 
238 
240 
242 
243 


CONTENTS 


Xlll 


CHAPTER 

XIV. 


GONORKHGEA    IN    THE    FeMALE       . 

History      ....•• 
Anatomical  Data  .  .  .  • 

Symptoms  of  GonorrhcBa  in  the  Female 
Mode  of  Infection  in  the  Female    . 

Direct  Infection    .  .  .  • 

Indirect  Infection 
Co-existence  of  other   Organisms  with  the   Gono- 

coccus  in  the  Female  Genito-Urinary  Tract  .    256 

Classification  of  Infections    .....   257 


PAGE 

245 
246 
247 
251 
254 
255 
256 


XV.    Treatment  of  Gonococcal  Infection  in  Women 
General  Treatment       ..... 
Treatment  of  External  Genital  Svirf  aces 
Treatment  of  Cervix    .  .  .  .  • 

Treatment  of  Vagina  .... 

Summary  of  the  Local  Treatment  in  the  Female 
Lactic  Acid  Bacilli       .  .  .  .  • 

Treatment  of  Chronic  Infections  in  the  Female 
Assurance  of  Cure  in  Female  Patients     . 


261 
261 
262 
263 
264 
264 
265 
268 
269 


XVI.     Complications    of    Gonococcal    Infection    in    the 
Female.         ....••• 
Bartholin  Abscess        ....•• 
Infected  Para-urethral  Passages  and  Vulvar  Pockets 
Infection  of  Skene's  Ducts    .  .  .  •  • 

Cystitis      ....•••• 
Extension  to  the  Kidneys     .  .  .  .  • 

Condylomata  Acvuninata      .  .  •  • 

Gonococcal  Infection  of  the  Uterine  Mucosa  . 
Gonococcal  Endometritis 
Symptoms  of  Acute  Endometritis 
Treatment  .  •  •  • 

Chronic  Gonococcal  Endometritis . 
Treatment  .  .  .  •  • 

Gonococcal  Infection  of  the  Fallopian  Tubes, 
Ovaries,  and  Peritoneum     . 
Symptoms  of  Salpingitis       .  .  •     ■ 

Treatment  .  .  .  •  • 

Gonococcal  Infection  and  Pregnancy 

Complications     .  .  .  •  • 

Condylomata  Acuminata 
Gonococcal  Infection  of  the  Placenta 

Gonococcus  in  the  Puerperium 


271 
271 

271 

272 
272 
273 
273 

273 

275 
275 
275 
276 
276 

279 
280 

281 
282 
283 
283 
283 
284 


XIV 


CONTENTS 


CHAPTER 

XVII. 


XVIII. 


Gonococcal  VuLvo-vAGI^^TIs  in  Children 
History      .... 
Etiology     .... 
Anatomy  and  Physiology 
Symptoms  of  Vulvo -vaginitis 
Diagnosis  .... 
Complications 

Prognosis  .... 
Treatment 


Condylomata  Acuminata  (Venereal  Warts) 
Histology  . 
Treatment 


XIX.     Gonococcal  Cystitis 
Symptoms 
Treatment 

XX.     Gonococcal  Infection  of  the  Kidney 
Paths  of  Infection 
Gonococcal  Pyelitis 
Treatment 
Pyelo -nephritis  . 
Treatment 

XXI.     Gonococcal  Infections  of  the  Eye 
History      ..... 
Etiology     ..... 
Ophthalmia  Neonatorum 
Incidence  of  Ophthalmia  Neonatormn 
Incubation  Period  of  Ophthalmia  Neonatorum 
Symptoms  of  Ophthalmia  Neonatorum 
Diagnosis  ,,  ,, 

Prognosis  ,,  ,, 

Proj)hylaxis  ,,  ,, 

Treatment  ,,  ,, 

Gonococcal  Conjunctivitis  in  the  Adult  . 
Treatment  of  Gonococcal  Conjunctivitis 
Corneal  Complications 

Treatment  by  Heat  of  Gonococcal  Ophthalmia 
Metastatic  Gonococcal  Eye  Disease 
Treatment  of  Metastatic  Gonococcal  Eye  Disease 
Gonococcal  Choroiditis 


PAGE 

285 
285 
285 
286 
287 
288 
289 
290 
290 

294 
295 
297 

301 
301 
302 

304 
304 
305 
306 
307 
307 

308 
308 
309 
309 
311 
312 
313 
314 
314 
315 
316 
320 
321 
321 
322 
323 
324 
324 


CONTENTS 


XV 


CHAPTER 

XXII. 

GONORRHCEAX   RHEUMATISM 

History      .          .          .          . 

Incidence  .          .          .          . 

Predisposing  Causes     . 

Classification 

Symptoms 

Diagnosis  . 

Prognosis  . 

Treatment 

PAGE 

.    325 

.    325 
.    325 
.    327 

.    328 
.    329 
.    330 
.    333 
.    333 

XXIII. 

GONOCOCCUS  Septicemia 

Classification  and  Etiology 
Symptoms 
Diagnosis  . 
Complications     . 
Prognosis  . 
•Treatment 

• 

.    336 

.    337 
.    338 
.    339 
.   339 
.    340 
.    340 

XXIV. 


XXV. 


Gonococcal  Atfections  of  the  Heart  and  Blood- 
vessels. ....•••    342 

Endocarditis       .......  342 

Symptoms  of  Endocarditis  .  .  ...  •  343 

Pericarditis  .......  344 

Phlebitis 344 


Gonococcal  Skin  Lesions 

Classification 

Keratodermia'Blenorrhagica 

Treatment 

Gonococcal  Infection  of  Skin  Wounds 


XXVI.     Immunity  Reactions 

Agglutination 
Opsonic  Action   . 
Precipitins 
Bactericidal  Action 

Complement  Deviation 

Technic  of  the  Complement  Deviation  Test 
Skin  Reaction     .  .  .  .  • 

Antigonococcus  Serum 

GoNOCOCcus  Vaccine    .... 


345 

345 
346 
347 
348 

349 

350 
350 

350 
350 

351 

354 
365 

357 

358 


XVI 


CONTENTS 


CHAPTER 

XXVII. 


Social  Aspects  of  Gonococcal  Disease 
Notification         .... 
Gonorrhoea  and  Marriage 
Method  of  Examining  the  Male 
Method  of  Examining  the  Female 
Prophylaxis  of  Venereal  Disease    . 
Printed  Instructions  for  Dispensary  Patients 


PAGE 

360 
360 
362 
363 
364 
365 
366 


Index  of  Names 
Index 


369 
371 


LIST  OF  ILLUSTRATIONS 

PLATES 

rebate     1.  TO   FACE    PAGE 

Film  of  pus  showing  Gonococci  (stained  Gram  and  counter- 
stained  1  in  10  carbol-fuchsin)  .  .  .  .  .  1 

Plate  2. 

Gonococci  from  Culture  (stained  Gram  and  counterstained  1 

in  10  carbol-fuchsin)    .  .  .  .  .  .  .  1 

Plate  3. 

Pxis  showing  Gonococci  ( Jenner  stain)     .....  1 

Plate  4t. 

Gonococcus   Cultures,    1    to    5   days'   growth.      (W.   Blair   M. 

Martin) 32 

Plate  5. 

Gonococcus  Cultures,   10  to   13  days'  growth.     (W.  Blair  M. 

Martin) 32 

Plate  6. 

Gonococcus  Colonies,   2  to    13  days'   growth.     (W.   Blair  M. 

Martin) 32 

Plate  7. 

Film  of  pus  showing  Gonococci  (stained  Gram  and  counter- 
stained  1  in  10  carbol-fuchsin)      .  .  .  .  .61 

Plate  8. 

Anterior  and  Posterior  Urethroscopic  Pictures.     (Chetwood)   .      172 

Plate  9. 

Amyloid  Bodies  in  the  Prostatic  Tubules  shown  on  Transverse 

Section.    (Taylor) 188 

Plate  10. 

Urethritis   and  Bartholinitis.      (Norris)  ....     253 

Plate  11. 

Lactic  Acid  Bacillus  .  .  .  .  .  .  .  •     263 

Plate  12. 

Section  of  Condyloma  Acuminatum  stained  with  Hsematein 

and  Eosin 295 

xvii 


XVlll 


LIST   OF  ILLUSTRATIONS 


ILLUSTRATIONS   IN  THE   TEXT 


Fig.  1.  Diagrammatic  representation  of  the  curves  and  dilata- 
tions of  the  iirethra     ...... 

„      2.     Male  pelvis  in  median  section     ..... 

„  3.  Showing  roof  of  urethra,  with  bristles  passed  into 
Littre's  folHcles.      (Taylor)   ..... 

„  4.  Microscopic  section  of  one  of  the  mucous  glands  or 
follicles  of  Littre  opening  into  the  lumen  of  the 
urethra.     (Taylor)  ...... 

„  5.  Showing  the  lacuna  magna  and  a  deeper  valve-Uke 
pocket  or  crypt,  and  the  orifices  of  numerous  mucous 
glands  or  crypts.    (Taylor)    ..... 

,,  6.  Transverse  section  of  the  membranous  urethra,  show- 
ing its  anatomical  structure.     (Taylor,  after  Testut) 

7.  Floor  of  urethra  and  base  of  bladder    .... 

8.  Section  through  the  prepuce  and  glans.     (Taylor) 

9.  Just  behind  the  meatus.     (Taylor)      .... 
10.     Through  the  prepuce  at  base  of  glans.     (Taylor) 
IL     Through  prepuce  and  corona  glandis.     (Taylor)  . 
.  12,  13.     Sections  just  behind  the  corona  glandis,  spongy  and 

cavernous  bodies  well  shown.     (Taylor) 
14  to  19.     Sections  from  before  backward  through  the  penile 
urethra.     (Taylor)         ...... 

Through     bulbomembranous     junction,     urethra    sur- 
rounded by  some  anterior  fibres  of  the  compressor. 

(Taylor) 

Through  apex  of  prostate.     (Taylor) 
Showing  the  position  of  the  ejaculatory  ducts  in  the 
middle  of  the  prostate  under  the  verumontanum 
just  before  they  turn  upward  and  end  in  the  pros- 
tatic vu-ethra.     (Taylor)         .  .  .  .  • 

Showing  the  position  of  the  ejaculatory  ducts  in  the 
lower  part  of  the  prostate  and  behind  the  urethra 
(Taylor)       ... 

All  glass  urethral  syringe 

MacMunn's  urethral  clamp 

Irrigating  apparatus 

Urological  basin 

Urethral  canulae 

Albarran's  vesical  syringe 

Glutton's  steel  sounds 

Acorn  and  olivary  tip  bougies 


Figs 


Fig.  20, 


21. 
22. 


23. 


24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 


43 

44 

45 


46 

47 

47 
48 
49 
49 
49 
49 

49 

50 


50 
50 


51 


51 
90 
91 
102 
103 
103 
106 
130 
131 


LIST   OF   ILLUSTRATIONS 


XIX 


Fig.  32. 
33. 
34. 
35. 
36. 
37. 
38. 
39. 
40. 
41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 


54. 


55. 

56. 

57. 
58. 
59. 


„  60. 

„  61. 

„  62. 

»  63. 


Filiform  bougies       .... 

Torpedo  sound  for  penile  infiltrations 

English  and  Charriere  catheter  gauges 

Watson's  dilating  sound  . 

Olivary-tip  bougies 

Watson's  straight  anterior  dilating  sound 

KoUmann's  dilators 

Electrolysis  needles  and  holder 

Burghard's  urethral  knife,  with  blunt  end 

Burghard's  sickle-shaped  urethral  knife 

Wyndhani  Powell's  urethral  punch   . 

Guyon's  syringe       .... 

Ultzmann's  syringe 

Hot-water  sound      .... 

Pollmann's  electrode  for  urethra 

Wyndham  Powell's  aero-urethroscope 

Luys's  urethroscope 

G.  S.  Gordon  dilating  urethroscope    . 

Joly's  urethroscope 

Wossidlo  urethroscope 

KoUmann's  suction  pipette 

Showing  a  section  (much  magnified)  through  one   of 

Tyson's   glands  in  the  prepuce  of   a  young  child 

(Taylor) 

Showing  section  (much  magnified)  of  normal  prostate 

of   a   subject   aged   nineteen   years,   made  througli 

middle  of  verumontanum.     (Taylor) 
Showing  prostate  of  a  man  in  which  senile  changes  are 

beginning  to  develop.     (Taylor)       .  .  .  . 

Bottcher's  sperma-crystals.    (Taylor) 
Rectal  tube  for  prostatic  hydrotherapy 
Watson's  prostatic  masseur        ..... 
Diagrammatic  view  of  bladder  from  behind  and  below, 

showing     relationship    between     prostate,    seminal 

vesicles,  vasa  deferentia,  and  ureters 
Showing  the  internal  structure  of  the  seminal  vesicle 

and  of  the  ampuUation  of  the  vas  deferens,  and  the 

union  of  the  two  ducts  which  form  the  ejaculatory 

ducts.     (Taylor)  ....... 

Showing  section  of  a  tubule  of  the  human  epididymis. 

(Taylor  after  Pearsol)    ...... 

Diagram  to  show  connection  between  prostatic  urethra, 

seminal  vesicles,  and  epididymis      .... 
Application  of  the  modified  triangular  bandage  . 


PAGE 

131 
132 
133 
134 
135 
136 
138 
140 
143 
143 
144 
145 
145 
146 
148 
153 
155 
158 
161 
163 
170 


178 


185 

186 
189 
198 
210 


214 

215 

225 

226 
235 


XX 


LIST  OF  ILLUSTRATIONS 


Fig.  64.  Epididymitis   and   paraphimosis.     Bier   treatment   of 

epididymitis  applied      .  .  .  .  .  .237 

„  65.  Parnell's  speculima  for  the  female  iirethra    .          .          .  272 

„  66.  Watson's  uterine  speculum         .....  278 

„  67.  Uterine  applicator  .......  279 

„  68.  Acute  gonorrhceal  salpingitis.    (Norris)       .          .          .  280 

„  69.  Gonorrhceal  salpingitis.    (Norris)        .          .          .          .  281 

„  70.  Vulvo-anal  masses  of  condylomata  acuminata     .          .  295 

„  71.  Condylomata  acuminata  of  prepuce  and  glans       .          .  296 

„  72.  All-rubber  goggles  .          .          .          .          .          ...  313 


PLATE  I. 


Film  of  pus  showing  Gonococci  (stained  Gram  and  counterstained  1  in  10  Carbol-Fuchsin). 


PLATE  11. 


Gonococci  from  Culture  (stained  Gram  and  counterstained  1  in  10  Carbol-Fuchsin). 


PLATE  III. 


'^:r  J 


Pus  showing  Gonococci  (Jenner  stain) 


GONORRHCEA 

AND  ITS  COMPLICATIONS 

IN  THE  MALE  AND  FEMALE 

CHAPTER    I 

HISTORY   OF   GONORRHOEA 

The  history  of  venereal  disease  has  attracted  much 
attention  from  syphilologists  within  recent  years,  and 
it  is  now  generally  accepted  that  syphilis  was  intro- 
duced into  Europe  by  the  mariners  of  Columbus  on 
their  return  from  the  New  World  in  1493.  Gonorrhoea, 
on  the  other  hand,  was  prevalent  in  Europe  long 
before  this  period,  references  to  this  disease  being 
frequent  in  the  earliest  writings.  As  the  centuries 
passed,  the  conception  in  the  minds  of  medical  writers 
gradually  attained  greater  clearness,  until  the  in- 
trusion of  syphilis,  when  the  identity  of  gonorrhoea 
was  lost  sight  of  and  all  venereal  disease  believed  to 
be  symptomatic  of  syphilitic  infection.  This  error 
held  sway,  not  undisputed,  however,  as  will  be  shown 
later,  until  the  painstaking  investigations  and  brilliant 
writings  of  Ricord  (1831-1860)  finally  overthrew  the 
heresy  and  laid  the  foundation  of  our  present  know- 
ledge of  gonorrhoea  as  a  specific  venereal  disease. 

Gonorrhoea,  a  Latin  word  of  Greek  origin,  is  first 
found  in  the  writings  of  Aretaios  of  Cappadocia,  a 
Greek   physician   who  lived   in   the   first   or   second 

WATSON.  — B 


2      GONORRHCEA  &  ITS  COMPLICATIONS 

century.  There  are,  however,  several  passages  in 
earlier  literature  which  justify  the  inference  that  the 
disease  was  prevalent  as  far  back  as  history  can  be 
elucidated.  Thus  the  Papyrus  Ebers,  the  oldest 
medical  Egyptian  record,  contains  prescriptions  to 
be  used  as  injections  for  genital  affections,  which 
suggest  the  occurrence  of  gonorrhoea  among  the 
Egyptians.  Proksch  states  that  in  a  Japanese  manu- 
script of  900  B.C.  there  is  a  vivid  description  of 
gonorrhoea.  Celsus  (25-35  a.d.)  speaks  of  the  disease 
as  a  flow  of  seed  "  sine  venere  vel  nocturnis  imagini- 
bus."  That  the  Jews  were  not  immune  is  proved  by 
verses  one  to  thirteen  of  the  fifteenth  chapter  of 
Leviticus,  and  this  reference  is  free  from  the 
erroneous  belief  regarding  the  nature  of  the  discharge 
which  influenced  Aretaios  in  adopting  the  misnomer 
"  Gonorrhoea." 

Aretaios  describes  gonorrhoea  as,  "A  very  dis- 
agreeable and  disgusting  disease  which  arises  in 
consequence  of  debility  of  the  sexual  organs.  In- 
voluntarily the  semen  flows  night  and  day,  thin, 
colourless,  and  unfruitful.  When  young  people  suffer 
they  develop  an  appearance  of  age,  become  lethargic, 
feeble,  spiritless,  and  palhd.  To  prevent  wasting  of 
the  body  and  loss  of  the  power  of  reproduction, 
gonorrhoea  must  quickly  be  removed."  The  function 
of  the  testicle  was  of  course  unknown,  the  semen 
being  beheved  by  the  Hippocratists  to  be  a  product  to 
the  formation  of  which  the  whole  body  contributed. 

Alexander  of  Tralles  (525-605)  still  considered 
gonorrhoea  a  discharge  of  semen,  but  he  divides  the 
causes  into  two  groups,  (a)  those  due  to  continence 
after  former  sexual  excess,  and  (b)  uninterrupted 
excess.  In  the  latter  case,  he  said  that  the  discharge 
was  acrid  and  irritating. 


HISTORY   OF   GONORRHCEA  3 

Towards  the  end  of  the  sixth  century  some  idea 
of  inflammatory  affections  of  the  urethra  developed, 
and  mention  is  found  of  pyuria,  haematuria,  and 
dysuria.  Paul  of  Mgina  noted  urethral  bleeding 
and  suppuration  without  admixture  with  urine. 

Avicenna  (980-1037)  and  his  contemporaries  are 
to  be  credited  with  some  advance  in  the  comprehen- 
sion of  this  question,  i^vicenna  describes  two  kinds 
of  urethritis,  (a)  one  in  which  the  urethra  is  bared  by 
too  frequent  coitus  of  its  protecting  mucus  and  in 
which  there  is  not  a  flow  of  suppuration  but  of  semen, 
and  (6)  one  in  which,  owing  to  internal  ulcer  or  ab- 
scess, there  is  discharge  of  pus  and  blood  accompanied 
by  burning  sensations.  He  remarked  that  the  first 
type  frequently  merged  into  the  second. 

Subsequent  to  a.d.  1000,  more  correct  descrip- 
tions of  the  disease  are  met  with,  and  we  find  coitus 
suggested  as  a  cause.  Maimon,  the  Jewish  theologian, 
philosopher,  and  physician  of  Cairo  (1139-1204)  men- 
tions several  causes  of  gonorrhoea,  and  includes 
amongst  these  lasciviousness  and  licentiousness.  The 
discharge _  he  describes  as  being  essentially  different 
in  its  nature  from  semen  and  mucus.  Valescus  of 
Taranta  (1380-1420)  writes  :  "  Not  only  is  gonor- 
rhoea harmful  to  the  individual,  but  to  the  whole 
human  race,  because  if  all  men  suffered  from  gonor- 
rhoea soon  would  the  whole  race  perish."  Roger 
(thirteenth  century)  details  the  symptoms  of  gonor- 
rhoea as  pain,  burning,  redness  and  swelling  of  the 
penis,  and  difficult  urination.  Guillaume  de  Salicet 
(thirteenth  century)  attributed  the  onset  of  gonor- 
rhoea to  impurities  retained  under  the  prepuce  after 
connection  with  an  unclean  woman.  He  was  the 
first  to  suggest  prophylactic  washing.  John  of 
Gaddesden  also  recommended  cleansing  with  acidu- 


4      GONORRHCEA  &  ITS  COMPLICATIONS 

lated  water  after  impure  cohabitation.  The  first 
mention  of  suspensory  bandages  is  found  in  his  book. 

These  extracts  enable  us  to  comprehend  the  views 
current  on  the  subject  of  gonorrhoea  previous  to  the 
advent  of  European  syphihs  in  the  last  decade  of 
the  fourteenth  century. 

Paracelsus,  in  1530,  had  begun  to  teach  that 
gonorrhoea  was  an  initial  symptom  of  syphilis,  but 
not  until  twenty  years  later  did  this  theory  gain 
support,  and  another  half-century  elapsed  before  it 
was  universally  adopted.  The  history  of  gonorrhoea 
thereafter  merges  into  that  of  syphilis,  and  this 
unfortunate  misconception  held  sway  until  finally 
overthrown  by  the  excellent  Avork  of  Ricord  begun  in 
1831  and  continued  until  1860. 

As  a  sample  of  the  accepted  doctrine  in  the  seven- 
teenth century,  Wiseman,  Surgeon  to  Charles  II, 
may  be  quoted.  In  his  publication,  "  Chirurgical 
Treatises,"  Treatise  VIII,  in  which  there  are  six 
chapters,  is  headed  "  Of  Lues  Venerea,"  and  the 
last  two  chapters  are  devoted  to  "  Gonorrhoea  "  and 
"  The  111  Consequences  of  Gonorrhoea  "  respectively. 
While  the  diseases  are  confused  as  regards  their 
etiology,  they  are  nevertheless  described  separately. 
One  of  his  definitions  is  as  follows  :  "A  virulent 
gonorrhoea  is  an  involuntary  emission  of  seed,  occa- 
sioned by  venom  contracted  from  an  unclean  woman." 
While  recognising  forms  of  gonorrhoea  other  than 
that  associated  with  syphilis,  he  says  :  "It  is  this 
species  that  is  the  most  usual  employment  of  our 
profession,  the  diseases  of  those  parts  being  most 
frequently  gotten  by  the  too  predominant  vice  of 
the  age."  The  misconception  of  a  common  cause 
led  to  mercury  being  prescribed  in  cases  which  were 
purely  gonorrhoeal,  but  as  a  rule  Wiseman  had  re- 


HISTORY  OF   GONORRHCEA  5 

course  to  mercury  only  in  obstinate  cases.  Of  the 
many  marvellous  combinations  of  drugs  for  which 
he  gives  prescriptions  the  outstanding  constituent 
apart  from  purgatives  is  turpentine.  He  used 
astringent  pills  and  injections,  but  to  milk,  which 
seems  to  have  been  popular  as  a  urethral  injection, 
he  objects,  on  account  of  its  liability  to  clot  in  the 
bladder.  He  recognised  prostatic  abscess,  epididy- 
mitis— for  which  he  enjoined  the  use  of  a  "  bag- 
truss  " — and  stricture,  which  he  ascribes  to  uncured 
"  caruncles,"  and  for  which  he  used  medicated 
candles  and  lead  probes.  He  described  perineal  sec- 
tion for  impermeable  stricture,  leaving,  however,  a 
permanent  fistula.  He  shows  considerable  ingenuity 
in  makinof  his  keen  clinical  observations  fit  in  with 
traditional  belief. 

During  the  eighteenth  century  several  writers 
threw  doubt  on  the  veracity  of  the  "  Unicist  Doc- 
trine "  of  Venereal  disease,  e.g.  Cockburn  (beginning 
of  eighteenth  century),  Francis  Balfour  (1767),  Charles 
Hales  (1770),  N.  Ellis  (1771),  I.  C.  Tode  (1774),  and 
Andrew  Duncan  (1777).  In  1793  Benjamin  Bell 
published  his  treatise  on  "  Gonorrhoea  Virulenta  and 
Lues  Venerea."  By  inoculation  experiments  on  two 
of  his  students  who  volunteered  their  services,  he 
proved  that  gonorrhoea  and  syphilis  were  distinct 
diseases. 

All  efforts  at  advance,  however,  were  nullified  by 
the  personal  experiment,  in  1767,  of  the  great  John 
Hunter,  who  unhappily  succeeded  in  contracting 
both  syphilis  and  gonorrhoea  from  an  inoculation  of 
impure  gonorrhoeal  pus.  His  prominence  in  the 
medical  world  caused  his  teaching  to  be  widely 
accepted,  and  the  efforts  of  his  few  opponents  to  be 
of  little   avail,   until   the   middle   of   the   eighteenth 


6      GONORRH(EA  &  ITS  COMPLICATIONS 

century,  when  Ricord  succeeded  in  convincing  the 
profession  of  the  duahty  of  gonorrhoea  and  syphihs. 
Ricord  failed  to  recognise  the  specific  nature  of  the 
gonorrhoeal  virus,  and  maintained  that  various  sources 
of  irritation,  e.g.,  lochial  and  leucorrheal  discharge, 
alcohohsm,  etc.,  could  produce  the  disease,  thus  con- 
fusing gonorrhoea  with  what  is  now  known  as  "  Ure- 
thritis Simplex."  Ricord  was  misled  by  having 
frequently  noticed  on  examination  that  a  man 
became  infected  with  an  acute  urethritis  while  the 
woman  with  whom  he  had  cohabited  was  free  from 
appreciable  disease.  By  his  discovery  of  the  gono- 
coccus  in  1879,  Neisser  settled  all  speculation  on  this 
subject. 

While  still  in  the  unicist  era  of  confusion  with 
syphilis,  the  advance  in  anatomical  knowledge 
gradually  led  to  a  better  understanding  of  the  local 
pathological  conditions.  Thus,  Tourquet  de  May  erne 
(1573-1655)  proposed  to  call  the  disease  "  puorroia," 
and  Wilham  Cockburn  (1715),  and  Morgagni  (1719) 
assisted  in  establishing  that  gonorrhoea  was  a  ure- 
thritis and  comparable  to  inflammation  of  other 
mucous  membranes  ;  but  it  took  many  years  to 
displace  the  erroneous  doctrines  current  in  their 
time  which  relegated  the  site  of  the  disease  to  the 
seminal  vesicles,  vas  deferens,  prostate,  or  Cowper's 
glands. 


CHAPTER   II 

BACTERIOLOGY   OF  GONORRHCEA 

The  first  successful  attempt  to  find  the  causative 
organism  of  gonorrhoea  was  that  of  Neisser.  While 
assistant  in  the  Breslau  Skin  Clinic  in  1879,  he 
published  an  article  entitled  "  On  a  Characteristic 
Micrococcus  of  Gonorrhoea,"  in  which  he  described 
the  microscopic  appearance  of  the  gonococcus  as 
seen  in  urethral  and  conjunctival  pus.  Neisser's 
discovery  was  rendered  possible  by  the  previous 
work  of  Weigert  and  Koch,  who  had  introduced  the 
process  of  bacteria  staining.  His  observations  were 
confirmed  by  others,  but  all  attempts  to  grow  the 
organism  on  artificial  media  failed  until  Bumm,  in 
1885,  successfully  used  solidified  serum  derived  from 
the  human  placenta.  The  separation  of  the  gono- 
coccus in  pure  culture  enabled  experimental  inocula- 
tions to  be  undertaken  on  the  human  subject,  and  the 
successful  issue  of  these  operations  conclusively 
demonstrated  the  causal  relationship  of  the  gono- 
coccus to  the  disease.  Wertheim  simplified  the  pro- 
cess of  culture  by  introducing  a  serum  agar  medium, 
and  blood  agar  or  serum  agar  is  now  in  common  use 
as  a  culture  medium. 

Microscopic  appearance  of  the  gonococcus. — The 
gonococcus  belongs  to  the  diplococci  group.  In  outline 
it  is  plano-convex  or  bean-shaped,  and  the  pairs  lie 
with  their  concave  or  plane  surfaces  opposing,  as 
shown  in  Plate  II,  leaving  usually  a  distinct  space 


8      GONORRHOEA  &  ITS  COMPLICATIONS 

between  the  cocci.  They  can  be  recognised  in  un- 
stained fihiis,  and  are  well  seen  by  dark  field  illumina- 
tion. They  have  no  capsule,  have  no  power  of 
movement  and  do  not  form  spores.  There  is  con- 
siderable variation  in  size,  but  the  average  measure- 
ment is  1-S  jw-in  length  and  -7  m  in  breadth.  The  cleft 
between  the  diplococci  is  one-fifth  of  the  breadth  of  a 
coccus.  Sometimes  two  adjacent  cocci  differ  in  size, 
and  considerable  variation  from  the  standard  occurs. 
In  purulent  secretion  they  are  usually  numerous  in 
the  pus  cells,  but  they  are  also  found  free  or  adhering 
to  ephithelial  cells.  Degenerated  cocci  may  be  seen 
in  convalescing  or  chronic  cases.  These  differ  from 
the  normal  coccus  in  shape,  size  and  power  of  absorb- 
ing stains,  but  are  said  to  be  still  capable  of  producing 
an  acute  gonorrhoea. 

Staining  of  gonococci. — The  gonococcus  readily 
absorbs  any  of  the  basic  anilin  stains,  e.g.,  methylene 
blue,  gentian  violet,  fuchsin,  etc.  It  is,  however, 
easily  decolorised  with  alcohol,  acids,  xylol,  and  other 
reagents,  and  thus,  in  staining  by  the  Gram  process, 
it  is  Gram-negative,  loosing  the  gentian  colour  and 
taking  up  the  counter  stain,  e.g.,  fuchsin.  Many 
special  methods  of  staining  gonococci  are  described, 
but  by  far  the  most  important  is  the  Gram's  stain,  as 
it  differentiates  the  gonococcus  from  all  Gram-positive 
organisms.  To  prepare  a  smear  in  a  suspected  case  of 
gonorrhoeal  infection  in  the  male,  cleanse  the  ex- 
ternal parts,  and  while  the  meatus  is  pressed  open, 
pass  a  small  bulbous-pointed  probe  wrapped  with 
sterile  cotton-wool  into  the  urethra  and  smear  the 
secretion  so  obtained  on  a  thin  glass  slide.  If,  on 
account  of  extreme  tenderness  of  the  urethra,  it  is 
not  advisable  to  use  a  probe,  the  meatus  and  sur- 
rounding parts  should  be  thoroughly  cleansed  with 


BACTERIOLOGY  OF  GONORRHOEA        9 

alcohol ;  a  drop  of  secretion  is  then  expressed  from 
the  canal  and  transferred  to  the  slide  by  direct  con- 
tact. The  pus  is  spread  on  the  slide  in  the  same  way  as 
in  making  a  blood  film. 

In  the  adult  female,  material  should  be  taken  both 
from  the  urethra  and  the  cervix.  In  females  it  has 
been  considered  difficult  to  get  a  smear  sufficiently 
free  from  contaminating  bacteria  to  be  of  much  use 
for  diagnostic  purposes,  but  if  the  following  method 
is  adhered  to  it  will  seldom  fail,  even  in  chronic  cases. 
After  cleansing  the  external  parts  with  sterile  water, 
the  urethra  is  treated  as  in  the  male.  The  cervix  is 
displayed  with  a  speculum,  the  external  os  wiped 
clean  with  wool,  and  the  cervical  canal  is  once  or 
twice  gently  but  firmly  swabbed  free  from  secretion 
and  surface  organisms.  A  third  probe  carrying 
sterile  wool  (or  a  platinum  spoon)  is  then  used  to 
collect  the  material  from  the  lining  epithelium  of  the 
canal,  and  this  is  applied  to  the  slide. 

The  smear  when  dry  is  fixed  by  passing  it  three  or 
four  times  through  the  flame  of  a  spirit  lamp  or  by  use 
of  the  Ehrlich  plate,  and  is  thereafter  stained  as 
follows  (Weigert-Gram)  : — 

1.  Stain    for    three    to    five    minutes    with    carbol- 

gentian- violet. 

2.  Dry  with  blotting-paper. 

3.  Treat  for  one  or  two  minutes  with  Gram's  Iodine 

Solution. 

4.  Dry  with  blotting-paper. 

5.  Decolorise  with  anilin-xylol    (anilin   oil  recently 

distilled  2  parts,  xylol  1  part). 

6.  Wash  with  xylol. 

7.  Allow  to  dry. 

8.  The    cell    elements    and    those    bacteria     which 

become  decolorised,  in  other  words  the  Gram- 


10    GONORRHOEA  &  ITS  COMPLICATIONS 

negative  organisms,  are  now  stained  with  diluted 
carbol-fuchsin  (1  to  10  of  water)  for  ten  seconds. 
9.  Wash  in  water  (gently  running  tap). 

10.  Ahow  to  dry. 

11.  Mount  in  xylol  balsam,  if  permanent  specimen 

desired. 

Under  the  oil  immersion  lens  the  appearance  of  the 
smear  will  vary  according  to  the  site  from  which  it 
has  been  obtained  and  the  stage  of  the  disease.  Thus 
the  smear  from  the  male  urethra,  if  taken  in  the  early 
stage  of  the  disease  before  there  is  much  pus  present, 
will  consist  of  mucus,  epithelial  cells,  leucocytes, 
and  various  micro-organisms.  The  normal  urethra 
has  been  said  to  entertain  as  many  as  sixteen  varieties 
of  saprophytes,  which  remain  innocuous  until  in- 
flammatory processes  are  set  up  either  by  mechanical 
irritation  or  by  the  gonococcus.  These  include  the 
bacillus  coli,  staphylococci,  streptococci,  etc.  They 
are  confined  to  the  pars  anterior,  the  posterior 
urethra  being  germ-free.  One  Gram-negative  dip- 
lococcus,  which  is  not  the  gonococcus,  is  found  in 
4  per  cent  of  urethras  ;  another  diplococcus,  not, 
however,  Gram-negative,  is  frequently  found  in  the 
male  urethra.  But  for  all  practical  purposes,  the 
discovery  of  a  Gram-negative  coffee-bean-shaped 
diplococcus  is  diagnostic  of  gonorrhoeal  infection. 
The  possibility  of  confusion  with  another  organism 
with  the  same  morphological  characters  to  be  found 
in  this  locality  is  so  remote  as  to  be  negligible,  in  the 
ordinary  circumstance  of  admitted  exposure  to  in- 
fection. 

In  the  early  or  mucous  stage  of  gonorrhoea,  the 
gonococci  are  for  the  most  part  extracellular,  and 
will  be  found  lying  free  in  pairs  or  groups  of  diplococci. 
In  the  middle  or  purulent  stage  many  pus  cells  will  be 


BACTERIOLOGY   OF  GONORRHCEA      11 

seen  containing  clumps  of  gonococci.  Cells  are 
occasionally  seen  crammed  with  them,  and  sometimes, 
owing  to  the  rupture  of  one  of  these  cells,  a  group 
which  has  in  appearance  been  compared  to  a  swarm 
of  bees  Avill  be  seen  in  the  field.  In  the  convalescing 
stages  the  gonococci  are  more  difficult  to  locate,  and  a 
whole  smear  may  contain  only  one  characteristic 
pair,  or  several  smears  may  have  to  be  searched 
before  any  gonococci  are  discovered. 

In  the  case  of  the  cervical  smear,  gonococci  are 
usually  identified  without  any  difficulty,  unless  in  old 
standing  cases,  and  then  several  attempts  may  be 
necessary,  or  some  artificial  method  of  stimulation 
may  have  to  be  adopted  to  demonstrate  their  presence. 
The  urethral  smear  in  women,  whose  infection  has 
been  of  remote  occurrence,  may  be  positive  even 
when  the  cervical  smear  has  failed  to  give  positive 
evidence,  and  this  is  especially  true  of  cases  compli- 
cated by  external  venereal  warts.  Smears  from  the 
cervix  are  often  very  mixed,  if  the  preliminary  dry 
cleansing  has  not  been  thoroughly  carried  out. 

A  short  description  of  the  various  organisms  likely 
to  be  found  in  smears  from  the  female  may  be  helpful. 
The  Bacillus  of  Doderlein  is  the  prominent  figure  in  a 
smear  from  the  healthy  vagina,  and  a  few  are  usually 
seen  in  a  cervical  smear.  Their  absence  from  the 
vagina  may  be  due  to  antiseptic  treatment  or  to  their 
having  been  crowded  out  by  contaminating  organisms. 
Doderlein  and  his  followers  attribute  to  this  bacillus 
an  active  part  in  the  protection  of  the  vagina  from 
invasion  by  other  bacteria,  and  they  ascribe  its 
antiseptic  powers  to  the  lactic  acid  which  it  produces. 
The  freedom  of  the  vaginal  walls  from  gonococcal 
infection  is  probably  due  to  Doderlein's  Bacillus,  as 
in    children,    where   the    vaginal    flora    has    not    yet 


12    GONORRHCEA  &  ITS  COMPLICATIONS 

appeared,  the  vaginal  walls  are  not  immune.  Under 
the  microscope  the  Doderlein  Bacillus  is  seen  to  be  a 
Gram-positive  organism  occurring  singly  as  well  as 
in  short  chains  of  from  two  to  four.  A  vaginal  smear 
showing  numbers  of  these  large  bacilli  and  but  few 
other  organisms  is  suggestive  of  a  healthy  condition 
of  the  parts.  It  is  a  serious  drawback  to  rigorous 
antiseptic  treatment  that  it  entails  destruction  of  this 
organism,  although  the  substitution  of  the  lactic 
acid  bacillus  to  a  considerable  extent  meets  this 
difficulty.  The  other  organisms  which  may  be 
encountered  are,  for  the  most  part,  Gram-negative 
small  and  large  bacilli  and  Gram-positive  cocci.  In 
addition  to  the  ordinary  pyogenic  staphylococci  and 
streptococci,  the  micrococcus  catarrhalis  and  pneu- 
mococcus  are  occasionally,  though  rarely  found.  The 
bacillus  coli  is  one  of  the  Gram-negative  bacilli 
frequently  present,  and  bipolar  staining,  which  it 
sometimes  shows,  may  give  it  an  appearance  sugges- 
tive of  the  gonococcus. 

Anaerobic  Gram-negative  bacilli  occur  in  large 
numbers  in  many  cases  of  vaginal  discharge  secondary 
to  gonococcal  infection,  and  these  organisms  may 
survive  after  the  disappearance  of  the  gonococci. 
They  are  liable  to  induce  balanitis  when  inoculated  on 
a  male  with  a  tight  prepuce. 

Gurd  has  described  a  "  diplobacillus  vaginae," 
which  is  commonly  present  in  vaginal  smears.  It 
is  short,  thick,  and  somewhat  lanceolate-shaped,  and 
occurs  in  pairs  with  the  broad  ends  approximated. 
Being  Gram-negative,  it  has  a  superficial  similarity 
to  the  gonococcus.  Innumerable  other  organisms, 
many  of  them  chromogenic,  are  found  in  vaginal 
smears.  Owing  to  morphological  similarity,  confusion 
may  arise  between  the  gonococcus  and  the  micrococcus 


BACTERIOLOGY  OF  GONORRHOEA      13 

catarrhalis  and  its  chromogenic  homologues.  The 
meningococcus  also  has  an  identical  microscopic 
appearance  and  staining  reaction,  and  can  only  be 
distinguished  by  cultural  methods.  It  has  not  been 
found  in  the  genito-urinary  tract.  Some  member  of 
the  micrococcus  catarrhalis  group,  commonly  found 
in  the  respiratory  passages,  may  on  a  rare  occasion 
be  met  with  in  inflammatory  conditions  of  the  male 
and  female  genitalia.  Microscopically,  they  appear 
somewhat  larger  than  gonococci,  but  only  by  cultiva- 
tion can  these  organisms  be  differentiated. 

In  order  to  stimulate  into  activity  and  thus  enable 
one  to  find  the  gonococci  in  cases  of  long  standing, 
whether  in  male  or  female,  various  methods  of 
irritation  may  be  adopted.  Locally  the  application  of 
strong  solutions  of  silver  salts,  instrumental  dilatation, 
massage,  etc.,  will  frequently  bring  gonococci  again 
into  prominence.  I  have  found  that  the  injection  of 
gonococcus  vaccine  has  the  same  effect  during  the 
"  negative  phase." 

Flakes  and  threads  found  in  the  urine  can  be 
cautiously  dried  on  a  slide  and  the  urine  salts  re- 
moved by  washing.  Urine  for  examination  should 
be  as  fresh  as  possible.  It  is  centrifugated ;  the 
deposit  washed  in  physiological  saline  and  recentrifu- 
gated. 

It  is  not  always  necessary  to  use  the  Gram  method 
of  staining,  e.g.,  in  following  the  result  of  treatment 
in  a  case  in  private  practice.  The  most  rapid  method 
would  be  to  stain  with  methylene  blue  either  in  a 
watery  solution  plain  or  with  addition  of  borax  ;  or 
Loeffier's  Solution  may  be  used.  The  stain  is  quickly 
absorbed,  and  the  specimen  is  then  washed  in  running 
water  and  dried  with  blotting-paper,  the  whole 
process   being   completed   within   one   minute.     The 


14    GONORRHCEA  &  ITS  COMPLICATIONS 

gonococci  are  deeply  stained  blue,  sometimes  so 
deeply  as  to  appear  almost  black,  the  cell  protoplasm 
but  slightly  stained  blue,  and  the  nuclei  are  distinctly 
blue.  Even  a  dilution  of  1/1000  of  methylene  blue 
gives  quite  good  results  (Bronnum). 

When  it  is  desired  to  retain  the  cell  elements  as 
slightly  altered  as  possible,  the  films  may  be  made  by 
placing  a  minute  drop  of  pus  on  a  cover  glass  and 
superimposing  another  clean  cover  slip.  The  two 
slips  are  separated  by  sliding  them  apart,  and  are 
allowed  to  stand  edgeways  until  dry.  They  are  then 
placed  in  equal  parts  of  absolute  alcohol  and  ether 
for  Mteen  minutes,  which  coagulates  the  albumen 
and  "  fixes  "  the  specimen.  Treat  according  to 
Gram's  method,  but  instead  of  merely  counter- 
staining  with  fuchsin,  a  more  complete  picture  can  be 
obtained  by  putting  the  films  into  methylene  blue  for 
one  minute,  washing  until  most  of  the  blue  has  dis- 
appeared, counterstaining  in  a  watery  solution  of 
eosin  for  twenty  to  thirty  seconds,  washing,  drying, 
and  mounting.  In  this  case  the  gonococci  retain  the 
blue  stain  and  the  cells  the  eosin. 

Loeffler  uses  a  stain  composed  of — 

4  parts  of  borax  methylene  blue. 

1  part  polychrome  methylene  blue. 

5  parts  -05%  bromeosin  B. 

He  exposes  the  preparation  to  the  action  of  this 
solution  for  one  minute,  with  slight  warming,  and 
then  decolorises  with — 

Alcohol,  177  parts. 

Solution  of  bromeosin  (1  in  1000),  20  parts. 

Acetic  acid,  3  parts. 

Pick  and  Jacobsohn  recommend  a  solution  con- 
sisting of— 


BACTERIOLOGY  OF  GONORRH(EA      15 

Distilled  water    ....      20-0  c.c. 
Carbol-fuchsin    .  .  .  .20  drops. 

Concentrated  alcoholic  methylene 

blue  solution  .  .  .        8      ,, 

To  be  applied  for  eight  to  ten  seconds.  Wash  in 
water.  Dry.  Gonococci  will  be  darker  than  other 
bacteria. 

The  Pappenheim  process  is — 

5%    Carbolic    water    solution    of 

Methylene  green  (concentrated)      2-0 
Pyronin 1- 0-3-0 

Stain  from  three  to  five  minutes.  Nuclei  blue-green 
to  lilac,  cocci  dark  red,  protoplasm  of  cells  rose-red. 

Krzysztalowitsz  has  modified  the  above  so  as  to 
shorten  the  exposure  to  twenty  to  thirty  seconds.  His 
solution  is — 

Methylene  green 
Pyronin 


Alcohol 
Glycerine 


2%  Carbolic  water 


015 
0-25 
2-5 
200 
to   100 


The  Schaffer  method  is — 

Dilute  carbol-fuchsin  (composed  of  fuchsin  0-1, 
alcohol  20-0,  5%  carbolic  water  200-0)  5  to  10 
seconds.      Wash. 

iEtheline  -  diamin  -  methylene  -  blue  solution  (com- 
posed of  coned,  watery  solution  of  methylene  blue 
2  to  3  drops,  and  1%  ^theline-diamin  10  c.c.) 
40  seconds. 

Dr.  A.  von  Wahl  suggests  a  new  stain  which  he 
says  acts  strongly  on  the  gonococcus,  and  is  particu- 
larly useful  in  cases  of  chronic  urethritis  and  for 
sections.    Its  composition  is — ■ 


16    GONORRHCEA  &  ITS  COMPLICATIONS 

Saturated  alcoholic  auramine  solution   .       2      c.c. 
Alcohol  (95%)      .  .  .  .  .1-5 

Saturated  alcoholic  solution  of  thionin    .       2-0    ,, 
Saturated  watery  solution  of  methylene 

green        .  .  .  .  .  .       3-0    ,, 

Distilled  water      .  .  .  .  .       6-0    ,, 

Expose  to  the  action  of  the  stain  for  five  to  fifteen 
seconds.  The  cellular  elements  are  coloured  light 
green  and  the  gonococci  dark  violet. 

Jenner's  stain  procures  a  good  picture  of  gonococcal 
pus. 

The  Gram  method,  however,  still  holds  its  position 
of  prominence  as  the  most  useful  stain  for  the 
gonococcus.  That  the  gonococcus  is  Gram-negative 
was  first  shown  by  Roux  in  1886.  Many  modifica- 
tions have  been  tried  to  improve  on  the  original 
procedure,  and  some  are  of  decided  advantage. 
The  anilin  water  solution  of  gentian  violet  being 
unstable,  has  to  be  prepared  anew  every  few  days. 
It  has  therefore  been  displaced  by  the  carbolic  water 
solution  (1  part  satd.  alcoholic  solution  of  gentian 
violet  mixed  with  ten  parts  5  per  cent  solution  of 
carbolic  acid).  Methyl  violet  is  preferred  by  some 
to  the  gentian  violet.  In  decolorising,  methylated 
spirit  is  better  than  absolute  alcohol,  but  Weigert's 
method  is  best  of  all.  He  uses  a  mixture  of  anihn  oil 
two  parts,  to  xylol  one  part,  and  washes  this  off  with 
xylol.  Anilin-xylol  decolorises  very  quickly.  A 
few  drops  are  poured  on  the  specimen  and  allowed  to 
flow  off  in  a  few  seconds.  This  is  repeated  once  or 
twice,  and  the  process  is  completed  by  washing  the 
oil  away  with  plain  xylol.  When,  on  the  first  addition 
of  the  anilin-xylol,  no  gentian  dissolves,  one  of  two 
faults  requires  correction,  (a)  the  specimen  is  too 
dry,  or  (b)  the  anilin  is  impure  or  old.     The  former 


BACTERIOLOGY  OF  GONORKHCEA      17 

can  be  overcome  by  breathing  on  the  film,  the  latter 
requires  a  freshly  distilled  anilin  oil.  The  xylol  dries 
off  rapidly  if  allowed  to  stand,  and  the  smear  is  then 
ready  for  counterstaining.  Where  spirit  is  used  for 
decolorising,  this  is  usually  complete  in  about  thirty 
seconds.  When  no  more  colour  is  removable,  the 
gonococci  are  always  stain-free,  and  the  specimen 
should  never  be  exposed  any  longer  than  two  to  three 
minutes  to  the  action  of  the  alcohol.  The  readiness 
with  which  the  gonococcus  parts  with  the  Gram's 
stain  is  influenced  somewhat  by  the  nature  of  the 
fluid  in  which  it  is  suspended.  Thus  Neisser  found 
that  a  film  from  a  pure  culture  required  fifteen  to 
twenty  seconds,  from  pus  twenty  to  thirty  seconds, 
and  from  mucoid  vaginal  secretion  sixty  seconds  or 
more. 

Wliile  an  organism  is  said  to  be  Gram-positive  if 
it  retains  the  stain  after  the  latter  has  been  com- 
pletely removed  from  the  tissues,  it  must  be  remem- 
bered that  some  tissue  elements  may  retain  the  stain 
as  persistently  as  any  bacteria,  e.g.,  keratinous 
epithelium,  calcified  particles,  the  granules  of  mast 
cells,  and  sometimes  altered  blood  cells,  etc.  (Muir). 

As  a  counterstain,  carbol-fuchsin  (Ziehl-Neelsen), 
diluted  with  ten  to  twenty  volumes  of  water,  applied 
for  a  few  seconds,  or  a  saturated  aqueous  solution 
of  Bismarck-brown,  will  stain  gonococci  red  or  brown 
respectively.  Degenerating  gonococci  tend  to  be- 
come spherical  and  swell  to  an  unusual  size.  These  are 
usually  Gram-negative,  but  are  indistinctly  stained. 

Vital-colouring,  i.e.,  the  staining  of  living  gono- 
cocci, can  be  effected  by  neutral  red  (Uhma).  Biber- 
geil  succeeded  with  various  basic  aniline  stains. 
F.  Winkler  rubbed  finely  ground  dyes  (neutral  red, 
pyronin,   fuchsin,   etc.)  into  the  urethra  and  found 

AVATSON. — C 


18    GONORRHCEA  &  ITS  COMPLICATIONS 

that  the  extraceUular  as  well  as  the  intracellular 
cocci  were  well  coloured  and  the  intervening  space 
between  the  cocci  well  defined. 

By  Plato's  method  the  living  gonococci  in  fresh 
pus  cells  can  be  rapidly  recognised.  His  solution, 
which  should  be  prepared  immediately  before  use, 
consists  of — 

Saturated  watery  solution  of  neutral  red   .       1  c.c. 

Normal  saline  solution    ....  100    ,, 

A  drop  of  pus  is  mixed  with  a  loopful  of  the  stain 
and  examined  under  a  cover  glass.  Only  the  in- 
tracellular gonococci  are  stained,  other  organisms, 
whether  intracellular  or  extracellular  as  well  as  the 
extracellular  gonococci  and  leucocytes,  remaining 
uncoloured. 

Staining  of  sections. — Tissue  sections  can  be  stained 
by  the  Gram,  the  Wahl,  or  the  Unna-Pappenheim 
process.  The  two  latter,  while  staining  the  gonococci 
distinctly  and  differently  to  the  tissues,  has  no  dis- 
criminating value  for  the  gonococcus  as  against 
other  organisms. 

Gram  method  recommended  for  sections. — 

1.  Stain    with    gentian    violet    for    five    to    fifteen 

minutes  according  to  the  density  of  the  tissue. 

2.  Treat   with   two   or  three   floodings   of   Gram's 

solution  and  allow  the  last  application  to 
remain  for  one  or  two  minutes.  The  tissue  is 
now  purplish  black. 

3.  Dry    with    blotting-paper    and   decolorise    with 

anilin-xylol.  Wash  with  xylol  and  allow  to 
dry. 

4.  Counterstain  the  Gram-negative  organisms  with 

dilute  carbol-fuchsin  for  thirty  seconds,  and 
wash. 


BACTERIOLOGY  OF  GONORRHCEA      19 

5.  Dehydrate  completely  in  absolute  alcohol,  clear 
with  xylol,  and  mount  in  xylol-balsam. 

As  a  contrast  stain  for  the  tissues,  carmalum  or 
carmine  may  be  used  before  beginning  the  above 
process. 

The  following  is  the  Unna-Pappenheim  method — 

Methyl-green  (Grubler)  .  .        0-15  gm. 

Pyronin  .  .  .  .  .        0-50    ,, 

Alcohol  (96  %)  .  .  .5-00  c.c. 

Glycerine  .  .  .  .      2000    „ 

Stain  with  gentle  heat  (incubator)  for  four  or  five 
minutes.  Wash  in  cold  distilled  water.  Dehydrate 
quickly  in  absolute  alcohol  and  clear  with  xylol. 
Mount  in  xylol-balsam.  The  gonococci  are  stained 
red  and  the  cell  nuclei  blue. 

The  stain  suggested  by  Wahl  has  already  been 
described. 

Cultivation  of  the  gonococcus. — Neisser's  work  with 
the  gonococcus  did  not  include  success  in  its  artificial 
cultivation.  This  was  reserved  for  Bumm,  who,  in 
1885,  succeeded  in  growing  colonies  on  solidified 
blood  serum  derived  from  the  human  placenta.  The 
next  investigator  to  announce  any  important  ad- 
vance on  Bumm's  methods  was  Wertheim  (1891). 
He  used  peptone  agar  and  human  serum,  two  parts 
of  the  former  to  one  of  the  latter.  The  serum,  at  a 
temperature  of  40°  C,  is  inoculated  with  the  gonor- 
rhoeal  pus,  mixed  with  fluid  agar  also  at  a  tempera- 
ture of  40°  C,  and  the  mixture  plated  and  incubated. 
By  this  method  colonies  of  the  gonococcus  may  be 
isolated  in  cases  of  mixed  infection  and  pure  growth 
obtained  by  subculture.  The  trouble  involved  in 
getting  sterile  human  serum  in  sufficient  quantity 
suggested  the  trial  of  ascitic,  pleuritic,  or  hydrocele 


20    GONORRHCEA  &  ITS  COMPLICATIONS 

fluids,  but  owing  to  the  variations  in  their  albumen 
content  and  in  their  alkahnity,  they  are  found  in 
practice  to  be  somewhat  less  reliable.  Blood  agar 
(Abel)  has  been  largely  tried  on  account  of  the  ease 
with  which  it  can  be  prepared  (simply  smearing  the 
surface  of  an  ordinary  agar  tube  with  a  few  drops  of 
blood  from  a  pricked  finger),  but  it  is  of  little  practical 
value.  Successful  attempts  have  been  made  to  grow 
the  gonococcus  on  various  animal  sera,  but  uniform 
results  have  not  been  obtained  by  different  observers. 
Urine  agar  in  the  proportion  of  one  to  two  is  recom- 
mended by  Finger  and  others.  Fluid  media  have 
not  proved  of  much  value,  although  pure  cultures 
can,  if  desired,  be  grown  in  ascitic  or  hydrocele  fluids 
or  serum  broths. 

An  analysis  of  the  many  papers  which  have  been 
published  on  the  subject  of  gonococcus  cultivation 
(as  well  as  one's  own  experience)  shows  vividly  how 
little  uniformity  can  be  obtained  by  different  workers 
with  any  of  the  above  media.  The  most  recent  work, 
however,  has,  I  think,  demonstrated  some  essential 
points  which  must  be  considered  in  the  choice  of  a 
medium  if  the  results  are  to  be  accepted  as  of  absolute 
diagnostic  value. 

Of  primary  importance  is  the  reaction  of  the 
medium.  Either  alkalinity  or  acidity  if  sufficiently 
marked  are  inhibitive  of  gonococcal  growth.  A 
reaction  as  nearly  identical  to  that  of  blood  serum 
as  it  is  possible  to  attain  is  the  ideal,  i.e.,  the  medium 
should  be  only  slightly  acid  to  phenol-phthalein 
(0-6  per  cent).  The  medium  must  also  contain  a 
small  proportion  of  uncoagulated  serum  albumen 
which  has  been  heated  to  57°  C,  in  order  to  destroy 
its  bactericidal  properties.  A  consideration  of  these 
points  has  enabled  Blair  Martin  to  compile  a  formula 


BACTERIOLOGY  OF  GONORRHCEA      21 

which,  in  my  experience,  has  proved  a  very  rehable 
medium.     Martin's  agar  is  prepared  as  folloAvs  : — 

"  A  beef  extract  is  prepared  as  usual.  To  it  are 
added  0-5  per  cent  of  di-sodium  phosphate,  1  per  cent 
of  Witte's  peptone,  and  2  per  cent  of  powdered  agar. 
The  mixture  is  placed  in  a  Koch's  steriliser,  and  after 
the  aofar  has  melted  the  medium  is  titrated  while  still 
hot.  For  this  purpose  I  take  a  5  c.c.  sample  of  the 
medium,  add  two  drops  of  a  |  per  cent  phenol- 
phthalein  solution,  and  then  run  in  a  one-twentieth 
normal  sodium  hydrate  solution  from  a  burette  till 
a  faint  but  permanent  pink  colour,  which  distinctly 
deepens  on  cooling,  appears.  This  is  taken  as  the 
end-point,  and  if  the  medium  is  of  the  correct  degree 
of  acidity  (0-6  per  cent  acid  to  phenol-phthalein  or 
6-0  on  Eyre's  scale)  0-6  c.c.  of  soda  solution  will 
have  been  used  (with  the  above  proportions).  In 
practice,  however,  more  alkali  is  at  first  required  : 
suppose  2  c.c.  were  used,  then  the  medium  is  1-4 
per  cent  (2—0-6)  too  acid.  This  is  corrected  by 
adding  to  the  medium  in  bulk  normal  sodium  hydrate 
solution  in  the  proportion  of  1-4  c.c.  to  each  100  c.c. 
of  medium  (usually  rather  more  than  the  calculated 
figure  is  actually  requisite).  The  reaction  having  been 
adjusted,  the  medium  is  filtered,  tubed,  and  sterilised 
as  usual.  Care  should  be  taken  to  avoid  prolonged 
cooking,  as  this  causes  a  darkening  of  the  medium, 
which,  by  masking  the  tints,  increases  the  difficulty 
of  titration.  Also,  if  white  of  egg  is  used  for  clearing 
purposes,  allowance  must  be  made  for  the  fact  that 
it  is  usually  more  acid  than  the  medium.  When 
properly  prepared  the  agar  is  practically  colourless, 
and  it  should  also  possess  only  a  moderate  amount  of 
water  of  condensation.  Too  moist  or  too  dry  a 
medium  is  a  fault." 


22    GONORRHOEA  k  ITS  COMPLICATIONS 

On  the  surface  of  each  agar  tube  Martin  runs  three 
or  four  drops  of  sterile  human  serum  which  has  been 
kept  at  57°  C.  for  an  hour  and  a  half.  When  the 
process  is  completed  the  tubes  are  incubated  for 
twenty-four  hours  to  ensure  that  they  are  sterile. 
This  also  allows  the  serum  to  dry  on  the  surface  of  the 
agar. 

Plating,  except  in  the  case  of  articular  effusion, 
has  no  advantage  over  slants,  and  it  introduces  a 
possibility  of  failure  in  the  fact  that  the  medium 
has  to  be  heated.  Martin  adds  0-2  c.c.  of  serum  to 
the  melted  agar  after  it  has  been  cooled  down  to 
45°  C.  Before  being  inoculated  it  has  to  be  further 
cooled  down  in  the  thermostat  to  40°  C,  as  the 
gonococcus  is  very  susceptible  to  heat,  surviving  only 
ten  minutes  in  a  temperature  of  44°  C.  and  being 
almost  immediately  destroyed  at  45°  C.  (Marcus). 

Another  trustworthy  medium  is  Gurd's  modifica- 
tion of  Duval's  formula.  This  medium  is  prepared 
as  follows  : — 

"  A  base  is  prepared  of  agar-agar  2  per  cent, 
peptone  1  per  cent,  sodium  chloride  -5  per  cent  added 
to  the  beef  infusion.  This  is  corrected  to  -6  per  cent 
acid  to  phenol-phthalein  (hot  titration)  before  sterili- 
sation in  the  autoclave.  To  the  tubed  sterile  agar, 
melted  and  cooled  to  a  temperature  of  52°  C,  is  added 
a  small  quantity  of  defibrinated  sterile  human  blood. 
From  four  to  seven  drops  of  blood  are  added  to  each 
six  to  ten  cubic  centimetres  of  agar.  The  tubes  are 
thoroughly  shaken  and  slanted  or  poured  into  Petri 
dishes.  By  this  means  a  beautiful  bright  crimson, 
almost  transparent,  medium  is  obtained  with  a 
moderate  amount  of  water  of  condensation.  If  the 
agar  is  hotter  than  60°  C.  when  the  blood  is  added, 
the  hemoglobin  is  destroyed  and  a  dirty  brownish- 


BACTERIOLOGY  OF  GONORRHCEA     23 

coloured  material  is  the  result.  If  the  agar  is  too  cool, 
there  will  be  no  water  of  condensation.  If  the 
medium  be  kept  for  one  or  two  weeks  before  being 
made  use  of,  growth  is  more  profuse  and  character- 
istic. The  water  of  condensation  may  be  conserved 
by  dipping  the  corks  in  hot  sterile  paraffin." 

With  this  medium  Gurd  says  that  he  has  never 
failed  to  obtain  growth  from  cases  in  which  the 
presence  of  the  gonococcus  could  be  otherwise 
demonstrated,  provided  that  antiseptics  have  not 
been  too  vigorously  used. 

The  usual  method  of  procuring  human  blood  is, 
after  severance  of  the  cord  at  a  confinement,  to  allow 
the  placental  end  to  bleed  into  a  sterile  bottle  con- 
taining a  few  glass  rods.  When  sufficient  blood  has 
been  collected  it  is  defibrinated  by  shaking.  The 
defibrinated  blood  is  used  for  Gurd's  medium,  and 
the  serum,  after  separation  of  the  corpuscles  by  the 
centrifuge,  for  Martin's.  A  simpler  method  of  ob- 
taining serum  for  Martin's  or  other  similar  medium, 
is  to  run  the  blood  into  a  sterile  test-tube,  allow  it 
to  clot,  and  pipette  off  the  resulting  serum  into 
sterile  tubing  which  is  sealed  in  the  blow-pipe. 
Store  until  required. 

Either  of  the  above  media  can  be  used,  confident 
that  if  gonococci  are  present  in  a  suspected  case  and 
the  infected  material  is  collected  and  applied  to  the 
tubes  with  careful  observation  of  the  necessary  pre- 
cautions, colonies  will  have  appeared  in  twenty-four 
hours.  The  method  of  procedure  in  taking  the  swabs 
has  already  been  described  on  page  8.  The  same 
swab  does  for  inoculating  the  culture  tube  and  for 
making  a  smear  for  microscopic  examination.  The 
tube  of  medium,  previously  warmed  in  the  incubator, 
receives   treatment   precedent   to   the   slide,    two   or 


24    GONORRHOEA  &  ITS  COMPLICATIONS 

three  successive  strokes  being  applied  to  the  slope. 
Particular  attention  has  to  be  paid  to  rapidity.  The 
swab  dries  quickly,  and  in  addition  to  the  fact  that 
the  gonococcus  soon  loses  its  vitality  if  allowed  to 
dry,  difficulty  would  be  experienced  in  seeding  the 
tube  and  also  in  smearing  the  slide  with  a  dried 
swab.  The  most  satisfactory  procedure  is  to  in- 
oculate the  tube  and  obtain  the  smear  direct  from 
the  patient,  and  with  as  little  delay  as  possible  to 
place  the  tube  in  the  incubator.  The  tube  should 
be  kept  from  drying  by  a  rubber  cap  or  by  dipping 
the  projecting  wool  plug  in  melted  wax.  If  an  hour 
or  two  must  elapse  before  the  incubator  is  reached, 
some  method  of  maintaining  the  tube  at  blood  heat 
should  be  adopted.  The  half -pint  thermos  flask 
holds  a  tube  comfortably,  and  cotton-wool  placed  in 
the  bottom  of  the  flask  moistened  with  water  at 
38°  C.  is  the  plan  I  prefer  for  the  conveyance  of 
inoculated  tubes. 

The  optimum  temperature  for  gonococcal  cultiva- 
tion is  36°  to  37°  C.  Above  41°  C.  and  below  32°  C. 
no  growth  takes  place.  The  minimum  at  which  it  has 
been  stated  to  retain  its  vitality  is  15°  C,  and  the 
maximum  44°  C,  but  it  is  probable  that  different 
strains  behave  differently  in  this  respect. 

The  appearance  of  the  colonies  varies  according 
to  the  medium  on  which  they  are  grown,  therefore  in 
the  following  description  I  have  confined  myself, 
for  the  sake  of  definiteness,  to  the  appearance 
as  seen  in  using  Martin's  medium,  and  have  largely 
drawn  on  Martin's  valuable  article  published  in  the 
"  Journal  of  Pathology  and  Bacteriology,"  vol.  xv., 
1910,  as  it  is  entirely  in  accordance  with  my  own 
observations  when  following  his  methods.  The 
colonies    are,    as    a    rule,     visible    in    eighteen    to 


BACTERIOLOGY  OF  GONORRH(EA     25 

twenty-four  hours  and  are  full  grown  in  forty- eight 
hours. 

"  They  are  minute,  semi-transparent,  slightly  ele- 
vated discs  presenting  to  the  naked  eye  a  moist- 
looking  glancing  surface.  When  examined  with  a 
low-power  lens,  they  are  almost  transparent,  of  a 
light  greyish-yellow  colour  with  transmitted  light. 
They  are  homogeneous,  the  ground  substance  being 
finely  granular,  and  they  have  definite  uniform 
margins  which,  under  a  high-power  lens,  are  seen  to 
be  very  slightly  toothed.  As  the  colonies  enlarge 
they  tend  to  remain  discrete  ;  the  centre  thickens 
and  gets  more  opaque,  owing  to  the  development 
of  numerous  ovoid  coarse  granulations ;  and  the 
margins  become  scalloped  instead  of  remaining  circu- 
lar (forty-eight  to  seventy-two  hours).  Then,  owing 
to  a  radial  plication  of  the  colony,  radial  striations 
develop,  and  concentric  rings,  due  to  zones  of  different 
degrees  of  opacity,  also  appear.  Finally,  in  about  a 
week,  still  coarser  granulations  become  visible  as 
points  of  supergrowth  throughout  the  colony,  and 
many  attain  a  considerable  size.  They  are  often  so 
white  and  opaque  in  contrast  to  the  rest  of  the 
colony  as  to  suggest  to  the  uninitiated  contamina- 
tions, but  when  examined  at  an  early  stage  with  a 
low-power  lens  the  appearance  is  exactly  that  of  a 
superimposed  daughter  colony.  When  touched  with 
a  platinum  loop  the  growths  are  readily  removed 
from  the  medium  :  they  have  a  distinctly  viscous 
consistence,  but  they  are  neither  slimy  on  the  one 
hand  nor  tenaciously  viscid  on  the  other,  and  cul- 
tures fairly  readily  emulsify." 

Gurd  describes  the  colonies  on  his  blood  agar  as 
follows  : — 

"  The    colonies    are    usually    well    developed    in 


26    GONORRHCEA  &  ITS  COMPLICATIONS 

eighteen  to  twenty-four  hours,  although  occasionally 
they  take  forty-eight  hours  to  reach  their  maximum 
size.  When  fully  developed  they  generally  appear 
as  raised  watery  -  looking  bluish -grey,  or  almost 
colourless,  semi-transparent,  small  round  colonies 
with  a  moderately  well-defined  outline.  The  colonies, 
as  a  rule,  in  seventy-two-hour  cultures,  show  a  ten- 
dency to  spread  out  from  the  periphery  in  a  more 
or  less  irregular  manner.  Upon  the  surface  of  the 
blood  agar  the  appearance  of  the  growth  is  very 
characteristic  and  readily  distinguished. 

"  As  a  rule,  the  colonies  measure  about  -8  milli- 
metre in  diameter.  Sometimes  they  are  extremely 
small,  being  scarcely  visible  in  the  initial  tube.  Upon 
several  occasions,  too,  in  which  the  organism  was 
proven  culturally  and  clinically  to  be  the  gonococcus, 
the  colonies  measured  from  two  to  four  millimetres, 
being  very  irregular  in  size  and  of  a  definitely  bluish- 
grey  colour  closely  resembling  the  characteristic 
colonies  of  the  meningococcus.  In  all  cases  the  sub- 
cultures from  such  colonies  gave  the  characteristic 
fine  watery  growth.  It  would  appear  that  certain 
bodies  in  the  fluid  in  which  the  organisms  were 
suspended  either  inhibited  or  assisted  the  subsequent 
growth  of  the  colonies. 

"  A  characteristic  of  the  growth  of  the  gonococcus 
which  is  more  marked  upon  blood  agar  than  on  other 
media  is  its  tenaciousness.  This  difficulty  in  the 
removal  of  colonies  is  especially  marked  in  colonies 
from  eighteen  to  thirty-six  hours  old.  This  character- 
istic is  also  met  with  in  the  cultivation  of  meningo- 
cocci." 

Curd's  cultures  when  kept  at  room  temperature 
were,  in  most  instances,  dead  within  a  week.  It  will 
be  noted  that  Martin's   description   of  the   colonies 


BACTERIOLOGY  OF  GONORRHCEA     27 

differs  somewhat  from  that  of  Gurd.  Particularly, 
his  measurements  are  greater,  and  he  describes  certain 
characteristics  which  are  not  evident  in  using  Gurd's 
medium.  Martin,  however,  admits  that  with  regard 
to  the  scalloped  margins,  radial  striations,  concentric 
rings,  and  granular  centre  considerable  differences  are 
evident  in  individual  specimens.  Any  of  these 
characters  may  be  wanting,  but  a  combination  of 
some  of  these  appearances  with  the  grey-bluish-white 
colour  and  moist  transparency  of  the  colony  serves 
to  differentiate  the  gonococcus  from  similar  colonies 
and  renders  a  diagnosis  possible  by  cultural  appear- 
ances. 

A  mixture  of  ascitic,  pleuritic,  or  hydrocele  fluid 
one  part,  and  ordinary  nutrient  agar  two  parts,  is 
largely  employed  for  the  growth  of  the  gonococcus, 
and  when  these  effusions  can  be  obtained  an  excel- 
lent and  reliable  medium  can  be  composed,  provided 
the  reactions  of  both  of  the  constituent  parts  are 
carefully  adjusted.  The  medium  I  now  prefer  for 
primary  culture  of  the  gonococcus  direct  from  the 
patient  is  made  as  follows  : — 

Liebeg's  extract  of  beef     .  .  .  -3  % 

Peptone           .          .          .  .  .  1  ,, 

Acid  phosphate  of  sodium  .  .  -5  ,, 

Glycerine          .          .          .  .  .  3  ,, 

Agar       .          .          .          .  .  .  2  ,, 

The  acidity  of  this  agar  is  reduced  by  the  addition  of 
sodium  hydrate  solution  to  a  point  which  varies 
according  to  the  reaction  of  the  ascitic  or  hydrocele 
fluid  in  stock,  but  it  is  usually  about  -3  to  phenol- 
phthalein.  In  reaction  these  transudates  are  usually 
shghtly  alkaline  to  litmus,  but  acid  to  phenol- 
phthalein,  the  degree  varying  from  -05  to  -8.     It  is 


28    GONORRHCEA  &  ITS  COMPLICATIONS 

therefore  necessary  to  titrate  the  serous  fluid  as  well 
as  the  agar,  in  order  to  know  what  the  total  acidity 
of  the  completed  medium  will  be.  The  reaction  of 
the  medium  should  not  exceed  -6  degree  of  acidity, 
but  may  be  as  low  as  -2.  Being  a  colour  test,  doubt- 
less there  is  some  variation  in  the  standard  of  different 
workers.  The  melted  and  tubed  agar  is  cooled  to 
56°  C,  and  a  portion  of  the  serous  fluid  is  then  added 
in  quantity  equal  to  half  the  volume  of  agar.  The 
tubes  are  sloped  and  afterwards  incubated  in  an 
inclined  position  to  ascertain  their  sterility  and  to 
encourage  the  exudation  of  water  of  condensation 
and  the  fixation  of  the  agar  to  the  glass.  This 
medium  improves  on  keeping. 

When  the  material  for  inoculating  the  tubes  is 
obtained  as  already  described,  a  good  growth  can  be 
anticipated  on  this  medium  in  positive  cases.  Colonies 
appear  in  sixteen  to  eighteen  hours  as  minute  and 
almost  transparent,  crystal  pinheads.  The  growth 
of  other  organism  seems  to  be  delayed,  so  that  it  is 
advisable  to  subculture  early  to  obtain  a  pure  culture. 
To  keep  a  strain  going  on  this  medium,  it  is  only 
necessary  to  subculture  once  in  three  weeks. 

On  agar,  as  a  rule,  no  growth  appears.  On  a  rare 
occasion,  especially  in  cases  where  there  is  little 
or  no  contamination,  some  colonies  may  develop. 
Where  this  happens  it  is  probably  dependent  on 
the  transference  during  inoculation  of  some  albumin- 
ous nutrient  material  along  with  the  micro-organisms. 
After  the  growth  of  some  generations  on  serum  or 
blood  agar,  subcultivation  on  agar  is  more  readily 
obtained.  Thalmann's  agar,  which  is  a  simple  meat- 
broth  agar,  neutral  in  reaction,  is  used  after  the 
addition  of  2  per  cent  of  glucose  as  a  medium  for  the 
subculture  of  gonococci  for  experimental  purposes,  as 


BACTERIOLOGY  OF  GONORRHCEA      29 

the  presence  of  serum  in  the  medium  compHcates  the 
results  in  sensitive  reactions  such  as  the  complement 
deviation  test.  A  plain  veal  agar  gives  better  but 
still  scanty  growth. 

Requiring  a  large  supply  of  gonococcus  extract  and 
finding  the  usual  serum-free  media  unsatisfactory, 
Hirschfelder  arrived  at  the  following  formula,  which 
he  says  removed  all  difficulties  : — 

"  Two  hundred  gm.  of  bullock's  testicle,  ground 
with  a  sausage-grinder,  were  boiled  with  1000  c.c.  of 
water  made  alkaline  with  sodium  hydroxid,  so  that 
10  c.c.  required  1  c.c.  tenth-normal  acid  to  neutralise 
to  phenol-phthalein.  This  was  filtered,  and  1  part  of 
this  testicular  extract  was  added  to  three  parts  of  agar 
prepared  as  follows  : — 

Veal  bouillon  .  .  .       gm.  or  c.c.  1000 

Saturated  solution  of  sodium 
phosphate  made  neutral  to 
phenol-phthalein  with  phos- 
phoric acid  ...  ,,  100 

Agar  .....  ,,30 

Agar  so  prepared  can  be  autoclaved,  and  on  it  the 
gonococcus  grown  readily." 

On  ordinary  gelatine  no  growth  takes  place,  but 
Turro  says  that  a  scanty  growth  of  delicate  colonies 
can  be  obtained  at  22°  C.  for  two  or  three  generations 
on  gelatine  which  has  not  been  neutralised  and  is 
therefore  acid.    No  liquefaction  occurs. 

Of  fluid  media  perhaps  the  best  is  that  recom- 
mended by  Bruschettini  and  Ansaldo  : — 

Sterile  beef  broth       .  .  .      10  c.c. 

Defibrinated  blood    ...        1  drop 
Fresh  white  of  egg     .  .  .       1     ,, 


30    GONORRHOEA  &  ITS  COMPLICATIONS 

Vannod  prefers  a  veal  broth  to  which  is  added  one- 
third  its  vohime  of  ascitic  fluid.  By  the  second  day  the 
medium  has  become  cloudy,  but  later  it  is  cleared  by  the 
deposition  of  the  growth  at  the  bottom  of  the  vessel. 

To  maintain  a  robust  growth  of  any  particular 
strain,  weekly  subcultures  are  advisable,  as  the 
organisms  soon  show  evidence  of  spontaneous  auto- 
lysis, increasing  considerably  in  size  and  losing  their 
affinity  for  stains. 

There  appears  to  be  some  doubt  as  to  whether  the 
gonococcus  can  survive  without  oxygen.  Wertheim 
and  Du  Mesnil  maintain  the  affirmative,  while  Van- 
nod  and  others  assert  that  it  is  an  obligatory  aerobe. 
An  atmosphere  of  hydrogen  hinders,  but  does  not 
prevent  growth.  In  vacuum,  Vannod  found  cultures 
sterile  in  one  hour,  but  this  may  have  been  due  to 
mechanical  injury  of  the   cells. 

From  urine  seven  hours  old  R.  Stein  succeeded  in 
growing  gonococci,  but  in  nine-hour  urine  the  organ- 
isms had  lost  their  vitality,  due,  he  suspects,  to  the 
presence  of  some  bactericidal  agent  in  the  urine. 

Films  from  cultures  show  the  characteristic  coffee- 
bean  diplococcus,  but  tetrads  are  not  uncommon. 
Considerable  variation  in  size  of  individuals  may  be 
seen  in  one  field. 

Degeneration  forms  are  early  present  in  culture 
films.  They  may  be  spherical  in  shape  and  either 
markedly  swollen  or,  on  the  other  hand,  they  may 
be  atrophied  and  shrunken.  When  a  culture  is  ulti- 
mately composed  only  of  such  forms,  it  is  still  cap- 
able (according  to  Wertheim,  Herman,  and  others) 
of  regeneration  on  transplanting  to  a  fresh  soil,  but 
this  assumption  is  open  to  the  criticism  that  the  new 
growth  may  be  due  to  normal  individuals  being 
present  which  have  escaped  recognition. 


DESCRIPTION   OF   PLATES  31 


DESCRIPTION   OF   PLATES   IV,   V,   AND   VI 

(From  the  "Journal  of  Patholog}'  and  Bacteriology,"  Vol.  XV.,  July,  1910. 
W.  Blair,  M.  Martin.) 

PLATE   IV 

Fig.  1. — Goiiococcus  (K.S.)^  stroke  culture,  1  day's  growth.  Note  the  ex- 
treme transparency  of  the  growth.     ( x  9  diameter.) 

Fig.  2. — Gonococcus  (S.),  stroke  culture,  5  days'  growth.  The  semi-confluent 
nature  of  the  growth  and  supergrowth  granules  are  shown. 
( X  9  diameter.) 

Fig.  3. — Gonococcus  (O.N.),  3  days'  growth.  Note  the  granularity  of  the 
centre.  There  is  slight  radial  striation,  but  the  margin  is  com- 
paratively circular.     (  x  9  diameter.) 

Fig.  4. — Gonococcus  (W.),  3  days'  growth.  Note  the  granular  centre,  the 
scalloped  margin,  and  the  radial  and  concentric  striation.  (  x  9 
diameter.) 

Fig.  5.  Gonococcus  (K.C.),  3  days'  growth.  Note  the  granular  centre  and 
the  general  plicated  nature  of  the  colony.     (  x  9  diameter.) 

Fig.  6. — Gonococcus  (C),  3  days'  growth.  Note  the  granular  centre  and 
the  extreme  plication  of  the  colony,     (x  9  diameter.) 

Fig.  7. — Gonococcus  (H.),  5  days'  growth,     (x  9  diameter.) 

Fig.  8. — Gonococcus  (K.S.),  5  days'  growth.  Note  the  extreme  degree  of 
marginal  scalloping.     (  x  9  diameter. ) 

Fig.  9. — Gonococcus  (V.),  5  days'  growth.  A  highly  typical  gonococcus 
picture  is  presented.  Contrast  with  Fig.  10,  which  shows  another 
colony  of  the  same  strain  grown  on  the  same  plate.  (  x  9  diameter. ) 

Fig.  10. — Gonococcus  (V.),  5  days'  growth.  To  contrast  with  Fig.  9.  There 
is  much  less  differentiation,  and  the  colony  was  more  opaque  as 
seen  with  the  naked  eye.     (  x  9  diameter. ) 

PLATE   V 

Fig.  11. — Gonococcus  (K.C.),  13  days'  growth.  The  granular  centre,  the 
plication  of  the  colony,  the  radial  and  concentric  striations,  and 
the  scalloped  margin  are  all  shown.  Note  commencing  super- 
growth  granulations  forming  a  zone  wliere  concentric  striation  is 
most  marked.     (  x  7|  diameter.) 

P'iG.  12. — Gonococcus  (K.C),  13  days'  growth.  Contrast  with  Fig.  11. 
These  colonies  were  grown  on  different  plates.  Here  there  is  a 
greater  degree  of  granularity  in  the  centre,  causing  opacity,  and 
supergrowth  granulations  are  more  marked,  but  concentric  stria- 
tion is  less  evident  than  in  Fig.  11.     ( x  To  diameter.) 

Fig.  13. — Gonococcus  (C),  10  days'  growth.  The  granularity  of  the  centre 
is  limited.  The  dark  circular  shadow  is  due  to  a  large  super- 
growth  out  of  focus.  The  plication  of  the  colony  has  given  the 
optical  effect  of  lily  leaves.     ( x  7§  diameter.) 


32    GONORRHCEA  &  ITS  COMPLICATIONS 


PLATE  VI 

Fig.  14. — Gonococcus  colony  appearances,  drawn  by  Mr.  A.  K.  Maxwell.     A 

light  and  shade  stereoscopic  effect  impossible  with  direct  photo- 
graphy is  thus  obtained. 

(a)  Gonococcus  (K.C.)^    2  days'  growth. 


{d) 

„       12 

(T.)      2 

.,  showing  tendency  of  colo- 
nies to  remain  discrete. 

(e) 
if) 

(T.)    12 
(K.C.)12 

,,  showing  supergrowth. 
.,  showing    few    but    large 
supergrowths. 

Fig.  1.5. — Gonococcus  (K.C.)^  6  days'  growth.  Note  comparative  translu- 
cence  of  whole  colony.  A  series  of  supergrowths  are  forming  a 
ring  midway  between  margin  and  centre.  (The  dark  central 
shadow  is  due  to  the  inoculating  point  having  cracked  the  surface 
of  the  medium.)     (x  9  diameter.; 

Fig.  16. — Gonococcus  (K.S.),  10  days'  growth.  Naked  eye  this  colony  was 
rather  opaque  and  without  central  granulation.  Note^  super- 
growths  have  appeared  at  one  place  near  the  margin.  ( x  9 
diameter. ) 

Fig.  17. — A  typical  arthritis  organism.  7  days'  growth.  Note  extreme 
plication  of  the  colony  and  its  comparative  opacity.  Coarse 
granulations  are  visible  on  the  surface.     (  x  9  diameter.) 

Fig.  18. — A  typical  arthritis  organism^  1.3  days'  growth.  Note  the  well- 
marked  coarse  granulation  of  the  central  portion.  (  x  7^  diameter.) 


PLATE  IV. 


Fis.  1. 


Fig. 


PLATE  V. 


Fig.  13. 


PLATE  VI. 


Pis'.    L: 


Fig.  16. 


Fie.  17. 


Fig.  IS. 


CHAPTER   III 

PATHOLOGICAL  HISTOLOGY   OF   GONOCOCCAL 
INFLAMMATION 

Tissue  changes  which  are  characteristic  of  bacterial 
infection  follow  the  trail  of  the  gonococcus.  Wherever 
the  organism  is  found  the  phenomena  of  inflammatory 
reaction  are  soon  apparent. 

The  gonococci  in  the  first  instance  grow  on  the 
surface  of  the  epithelium.  The  production  of  toxine 
by  the  surface  colonies  is  followed  by  hypersemia  and 
serous  exudation.  As  a  result,  the  cylindrical  epi- 
thelial cells  become  swollen  and  loosened,  and  they  are 
cast  off  in  considerable  numbers.  Small  blood-vessels 
are  seen  crammed  with  leucocytes,  and  diapedesis  and 
phagocytosis  are  soon  in  active  progress  producing 
the  characteristic  purulent  discharge.  Polynuclear 
leucocytes,  mononuclear  leucocytes,  and  plasma  cells 
are  deposited  in  the  subepithelial  tissue,  the  concentra- 
tion of  these  wandering  cells  being  greatest  im- 
mediately subjacent  to  the  epithelial  layers. 

Between  the  interstices  of  the  separating  cylindri- 
cal epithelium,  gonococci  find  suitable  conditions  for 
growth.  They  are  found  in  rows  around  the  cells, 
but  never  actually  within  the  epithelial  cells.  Epi- 
thelium of  the  squamous  type  is  more  resistant 
to  the  gonococcal  toxine,  and  while  colonies 
flourish  on  the  surface,  they  have  no  chance  of 
becoming  insinuated  into  crevices  between  and  be- 
neath the  cells  in  contradistinction  to  what  occurs  in 

WATSON'. — D  33 


34    GONORRH(EA  &  ITS  COMPLICATIONS 

the  case  of  cylindrical  epithelium  ;  and  therefore  so 
long  as  they  are  confined  to  the  fossa  navicularis, 
gonococci  are  exposed  to  the  action  of  abortive  anti- 
septic treatment.  In  the  case  of  cylindrical  epi- 
thelium, gonococci  readily  reach  the  corium  and 
frequently  also  its  submucous  tissue.  On  the  surface 
they  are  carried  into  the  lacunae  and  the  gland  ducts, 
where,  being  beyond  the  reach  of  injected  antiseptics, 
they  may  remain  for  indefinite  periods  in  susceptible 
individuals.  If  they  succeed  in  penetrating  any  long 
gland  tubule  the  surrounding  corpus  spongiosum 
becomes  infiltrated. 

In  the  epithelial  layer  are  found  many  polynuclear 
leucocytes,  while  in  the  connective  tissue  lympho- 
cytes preponderate,  and  their  number  is  greatly 
increased  as  the  gonococci  reach  into  the  depths 
of  the  corium.  Wherever  gonococci  penetrate  the 
infiltration  is  intense,  and  the  abundance  of  the  in- 
filtrating cells  varies  in  proportion  to  the  number 
of  organisms. 

As  the  gonococci  pass  along  the  lymph  channels 
they  set  up  more  or  less  lymphangitis.  Endarteritis 
has  also  been  proved,  and  occasionally  thrombo- 
phlebitis has  been  noticed. 

The  organisms  embedded  in  the  tissues  are  nearly 
all  extracellular,  but  occasionally  some  are  seen  in  the 
interior  of  a  polynuclear  leucocyte.  The  only  cells 
which  absorb  gonococci  are  the  polynuclear  neutro- 
phile  leucocytes ;  mast  cells  and  eosinophile  cells 
never  show  gonococci  in  their  protoplasm.  The 
intracellular  position  becomes  more  common  nearer 
the  surface,  but  phagocytosis  is  most  active  of  all  in 
the  lumen  of  the  urethra.  This  is  proved  by  the 
observation  that  the  discharge  obtained  at  the  meatus 
shows    a    much    greater    proportion    of    intracellular 


GONOCOCCAL   INFLAMMATION         35 

gonococci  than  is  found  in  smears  collected  from  the 
surface  of  the  mucous  membrane  after  the  passage 
has  been  cleansed  by  the  act  of  micturition. 

As  the  purulent  stage  subsides  the  denuded  areas 
of  epithelium  are  regenerated  in  the  first  place  by 
the  growth  of  layers  of  flattened  epithelial  cells.  There 
may  be  at  certain  spots  many  layers  of  squamous 
cells  heaped  up  in  such  a  manner  as  to  form  minute 
excrescences.  These  are  ultimately  shed  in  flakes, 
and  when  all  irritation  has  been  removed  the  flattened 
epithelium  is  finally  replaced  by  healthy  cylindrical 
cells. 

In  the  process  of  healing  two  factors  are  con- 
cerned, namely,  a  new  deposition  of  resistant  squam- 
ous epithelium  and  the  production  of  antibodies. 
The  squamous  epithelium  prevents  any  recruiting 
of  the  tissue-embedded  gonococci  from  the  surface. 
The  toxine  produced  by  the  interstitial  gonococci  is 
diverted  into  the  ordinary  channels  of  absorption 
instead  of  escaping  in  the  exudation  through  the 
disintegrated  mucosa.  Reaching  the  blood  stream 
it  acts  as  a  natural  vaccine  stimulating  the  formation 
of  antibodies,  the  presence  of  which  in  the  serum 
makes  it  not  only  an  unsuitable  medium  for  the 
growth  of  the  gonococcus,  but  brings  about  the 
destruction  of  the  organisms.  In  this  way  it  may  be 
suggested  the  gonococci  disappear,  and  eventually 
by  the  action  of  the  plasma  cells  the  infiltration  also 
becomes  absorbed. 

The  ^pathological  changes  in  chronic  urethritis. — 
There  is  unfortunately  a  distinct  tendency  in  a  con- 
siderable proportion  of  cases  for  the  processes  which 
are  productive  of  cure  to  stop  short  of  completeness 
and  for  the  gonococcus  to  maintain  its  existence  in 
certain  areas  although  its  activities  are  restrained. 


36    GONORRHOEA  &  ITS  COMPLICATIONS 

In  chronic  urethritis  gonococci  are  most  fre- 
quently found  in  gland  ducts  where  they  may  main- 
tain a  subdued  activity  for  indefinite  periods, 
extending  sometimes  to  years,  but  they  may  also 
survive  for  some  time  in  the  depths  of  the  mucosa. 
In  either  situation  they  are  not  within  reach  of 
local  antiseptic  treatment,  and  the  difficulty  of  ex- 
terminating the  organisms  is  much  increased.  The 
intraglandular  situation  of  the  gonococci  explains  the 
marked  tendency  to  the  periglandular  localisation  of 
the  infiltrated  areas  so  noticeable  in  chronic  gonococ- 
cal urethritis. 

In  the  presence  of  a  continued  irritation  the  sur- 
rounding infiltration,  instead  of  becoming  absorbed, 
undergoes  a  series  of  changes  which,  unless  they  are 
checked,  result  eventually  in  the  formation  of  cicatri- 
cial tissue.  New  blood-vessels  find  their  way  between 
the  infiltrating  cells,  and  the  latter  are  gradually 
replaced  by  newly  formed  connective  tissue  cells. 
The  next  retrograde  change  is  marked  by  the  appear- 
ance of  white  fibres,  and  the  new  granulation  tissue 
becomes  insidiously  converted  into  cicatricial  tissue. 
The  over-production  of  connective  tissue  cells  with 
subsequent  formation  of  connective  tissue  fibres  is 
the  characteristic  histological  change  in  chronic 
urethritis,  and  it  is  of  the  greatest  clinical  significance. 

Clinically,  the  different  stages  are  recognised  as 
"  soft  "  and  "  hard "  infiltrations,  and  the  final 
cicatrix  in  unfavourable  cases  results  in  the  pro- 
duction of  a  stricture.  In  acute  gonorrhoea  the 
infiltrated  areas  are  of  the  soft  variety,  and  in  the 
early  chronic  stage  little  change  is  manifest ;  but  as 
time  goes  on,  if  the  irritation  is  still  maintained, 
fibroblasts  make  their  appearance,  with  later  a 
deposit  of  fibrous  tissue.     These  histological  changes 


GONOCOCCAL   INFLAMMATION         37 

are  accompanied  by  the  physical  changes  indicated 
by  the  nomenclature  of  the  above  classification,  viz., 
soft,  hard,  and  cicatricial. 

When  the  gonococci  are  confined  to  a  gland  or 
lacuna  the  orifice  may  become  occluded,  in  the  early 
stages,  by  the  swelling  of  the  oedematous  and  in- 
filtrated mucosa  or  by  a  plug  of  hardened  detritus, 
and  in  the  later  stages  by  contraction  of  the  newly- 
formed  fibrous  tissue  or  adhesions  of  the  eroded  duct 
walls.  A  cystic  abscess  is  the  result,  and  this  can  be 
felt  as  a  tensely  firm  body  varying  in  size  from  a 
caraway  seed  to  a  pea  or  even  larger.  These  pseudo- 
abscesses  usually  rupture  into  the  urethra,  and  their 
alternate  filling  and  emptying  is  occasionally  the 
explanation  of  mild  exacerbations.  When  this  pus 
formation  is  limited,  the  contents  of  the  cyst  tend 
through  time  to  become  sterile,  in  which  case  a 
nodule  may  remain  or  it  may  become  absorbed, 
leaving  only  a  minute  scar. 

The  intrusion  of  other  organisms,  "  mixed  infec- 
tion," increases  the  risk  of  the  pro,duction  of  a  true 
abscess,  the  cyst  wall  being  destroyed.  Such  an 
abscess  will,  on  a  rare  occasion,  point  externally, 
when  a  troublesome  fistula  may  be  anticipated. 

Another  effect  of  cicatricial  contraction  in  the 
neighbourhood  of  a  gland  is  gaping  of  the  orifice. 

On  examining  through  the  urethroscope,  chroni- 
cally infected  glands  may  thus  present  as  small 
bulging  cysts,  as  dilated  and  reddened  openings,  or 
remnants  only  can  be  seen  as  minute  cicatrices. 

The  curative  changes  in  the  epithelium  may  be 
retarded  or  may  be  exaggerated.  The  piling  up  of 
numerous  layers  of  squamous  cells,  the  most  super- 
ficial of  which  are  frequently  keratinised,  produces 
callosities  projecting  beyond  the  level  of  the  surround- 


38    GONORRHCEA  &  ITS  COMPLICATIONS 

ing  mucous  membrane.  The  epithelium  is  shed  in 
flakes  of  considerable  size,  and  overlying  certain 
areas  of  infiltration,  erosions  or  patches  of  granulation 
tissue  are  sometimes  found. 

The  histological  pathology  of  post-gonorrhoeal  dis- 
ease is  identical  with  that  of  late  chronic  gonococcal 
urethritis,  the  essential  distinguishing  feature  being 
the  absence  of  the  gonococcus. 


CHAPTER   IV 

ACUTE   GONOCOCCAL  URETHRITIS  IN  THE   MALE 

Acute  catarrhal  inflammation  of  the  urethral  mucous 
membrane  in  the  male  is  in  the  great  majority  of 
cases  due  to  invasion  by  the  gonococcus.  A  "  simple  " 
urethritis  in  which  the  gonococcus  is  not  the  causative 
agent  is  not  of  very  rare  occurrence,  and  it  will  be 
considered  in  a  later  chapter  ;  but  at  the  present 
day  no  difficulty  can  be  encountered  in  arriving  at  a 
definite  diagnosis,  as  in  every  case  both  diagnosis 
and  treatment  should  be  controlled  by  bacteriological 
examination. 

On  the  occasion  of  an  impure  coitus,  the  gonococcus 
is  implanted  from  an  infected  urethra  or  cervix  into 
the  urethral  canal  of  the  male,  at  once  reaching,  in  all 
probability,  the  fossa  navicularis,  to  which  for  a  time 
its  location  is  limited.  The  epithelial  lining  of  the 
fossa  navicularis  being  of  the  squamous  type  and 
resistant  to  the  gonococcus,  the  organism  lives  on 
the  secretions  in  the  canal.  At  this  stage  it  is  there- 
fore easily  destroyed  or  removed  by  suitable  prophy- 
lactic treatment.  The  gonococcus  itself  having  no 
power  of  movement  is  dependent  for  its  reception 
into  the  navicular  fossa  on  the  suction  action  which 
follows  ejaculation.  Its  upward  spread  thereafter  is 
due  to  the  propagation  of  the  colonies  on  the  surface 
of  the  mucos^a,  to  the  collection  of  the  retained  dis- 
charge during  the  night,  and  possibly  also  suction 
action  following  urination.     The  explanation  of  the 

39 


40    GONORRHCEA  &  ITS  COMPLICATIONS 

suction  action  referred  to  is,  that  following  the  ex- 
treme spasmodic  contraction  of  the  muscles  capable 
of  compressor  and  expulsive  action,  a  current  in  the 
opposite  direction  is  set  in  action  by  the  creation  of 
a  vacuum  until  the  normal  condition  of  tonic  con- 
traction is  re-established. 

Extra-venereal  infection,  while  uncommon  in  adults, 
is  not  unknown.  In  practice  I  have  encountered  five 
such  cases  in  whose  bona  -fides  I  could  rely.  One 
occurred  to  a  medical  practitioner  who,  having 
shaken  hands  on  parting  with  an  infected  patient, 
proceeded  to  urinate  before  washing  his  hands.  Two 
cases  were  infected  from  towels  used  by  house- 
mates ;  another  from  a  lavatory  seat ;  and  the 
fifth  from  a  speculum  in  a  gynaecological  dispensary. 
A  number  of  similar  cases  have  been  reported,  and 
while  one  receives  such  histories  with  incredulity  in 
most  cases,  it  has  to  be  admitted  that  not  only  are 
they  possible,  but  that  they  actually  do  occur.  In 
female  children  it  is  common  for  infection  to  spread 
through  families  and  also  among  the  inmates  of  in- 
stitutions, so  that  in  the  case  of  an  infected  child 
rigorous  measures  for  prevention  should  be  adopted 
without  delay. 

While  one  attack  does  not  confer  immunity  from 
future  attacks,  it  is  probable  that  in  many  cases  it 
modifies  the  course  of  a  later  infection  by  decreasing 
the  acuteness  of  the  symptoms  and  developing  a 
greater  tendency  to  chronicity.  This  observation  is, 
however,  open  to  the  criticism  that  such  cases  are 
really  exacerbations  of  former  uncured  gonorrhoeas 
induced  by  excessive  indulgence. 

The  acuteness  of  the  symptoms  is  influenced  by  (a) 
the  virulence  of  the  organisms  ;  (&)  the  number  of 
cocci  gaining  access  to  the  interior  of  the  urethra  ; 


URETHRITIS    IN   THE   MALE  41 

(c)  the  general  resistance  of  the  patient ;  and  (d)  the 
sensitiveness  of  the  urethral  mucosa.  Young  and 
virginal  subjects  are  specially  liable  to  acute  attacks. 
A  soft,  delicate  mucosa  seems  to  afford  the  most 
favourable  medium  for  the  activities  of  the  gonococ- 
cus.  Several  men  may  have  intercourse  with  the 
same  female  shortly  after  one  another  and  not  all 
be  infected.  Urination  and  washing,  apart  from  any 
more  active  prophylactic  measures,  may  assist  an 
occasional  escape.  The  fact  that  for  several  hours 
the  infection  is  localised  superficially  in  the  fossa 
navicularis  suggests  the  practicability  of  an  effective 
prophylaxis,  and  this  will  be  considered  later. 

Period  of  incubation. — From  the  time  of  infection 
until  the  appearance  of  the  first  symptoms  a  period 
^  ^,^^M^f  two  to  seven  days  elapses.  In  the  largest  per- 
centage of  cases  the  incubation  period  is  three  days, 
but  in  many  cases  when  the  disease  is  being  looked 
for  suspicion  will  be  aroused  in  twenty-four  to  thirty- 
six  hours,  and  it  can  then  be  verified  by  the  micro- 
scope. The  symptoms  have  in  a  few  cases  been  quite 
well  established  in  twenty-four  hours,  and  on  the 
other  hand  they  may  be  delayed  three  weeks  or  even 
longer.  Delay  is  due  to  increased  resistance  on  the 
part  of  the  patient  or  to  a  low  degree  of  virulence  on 
the  part  of  the  organism,  or  failure  of  the  organism 
immediately  to  reach  the  urethra,  it  being  located 
in  the  first  instances  elsewhere,  e.g.,  in  a  para-urethral 
passage  from  which  later  the  urethra  becomes  in- 
fected. 

It  has  been  found  that  many  men  as  well  as  women 
harbour  the  gonococcus  for  long  periods,  years  it 
may  be,  without  discomfort  to  themselves,  and  some 
of  these  infected  men  and  many  of  the  women  deny 
having  had  any  of  the  classical  symptoms  of  gonor- 


42    GONORRHOEA  &  ITS  COMPLICATIONS 

rhoea.  These  "gonococcus  carriers  "  are  a  prolific  source 
of  disease,  all  the  more  dangerous  because  they  are 
unconscious  of  the  extent  of  the  injury  they  are 
inflicting.  Excitement,  physical  exercise,  or  alco- 
holism may  in  such  cases  give  rise  to  the  appearance 
of  acute  symptoms  apart  from  any  fresh  infection. 

Exacerbations  incubate  as  a  rule  more  quickly 
than  new  infections  (one  to  two  days).  In  inoculation 
experiments  the  incubation  period  has  been  two  to 
three  days. 

As  it  is  probably  the  toxine  of  the  gonococcus 
which  excites  the  inflammation,  the  delay  in  the 
appearance  of  the  symptoms  is  not  due  merely  to  the 
time  required  for  the  propagation  of  colonies,  but 
to  the  time  required  before  the  organisms  by  their 
degeneration  and  disintegration  liberate  endotoxine 
in  sufficient  quantity  to  excite  a  pronounced  reac- 
tion. 

Another  explanation  of  the  incubation  period  is 
that  thirty-six  to  forty-eight  hours  expire  before  the 
gonococci  are  found  penetrating  between  the  cells 
into  the  tissues,  and  it  is  these  organisms  which 
stimulate  nature's  resisting  forces  expressed  in  the 
phenomena  of  inflammatory  congestion  and  exudation. 


GONOCOCCUS   INVASION   OF  THE   MALE   URETHRA 

Anatomical  considerations. — The  average  male  ure- 
thra measures,  when  slightly  stretched,  about  eight 
inches  in  length,  but  variations  within  the  limits  of 
six  to  ten  inches  may  exist  without  abnormality. 
Except  when  the  lumen  is  distended  by  fluids  or 
instruments,  the  walls  of  the  urethra  remain  in  ap- 
position. The  distensibility  varies  from  8  millimetres 
at   the   meatus   to    14    millimetres    in   the   prostatic 


URETHRITIS   IN   THE   MALE  43 

portion.  Figure  1  shows  the  natural  dilatations, 
constrictions,  and  curves  of  the  canal.  The  narrowest 
point  is  at  the  meatus,  which  has  a  diameter  of 
8  millimetres.  This  is  followed  by  a  widened  area, 
the  fossa  navicularis  which  contracts  in  the  penile 
portion  to  10  millimetres.  At  the  bulb  there  is  again 
an  increase  to  13-15  millimetres,  which  at  the 
membranous  portion  is  suddenly  reduced  to  9-10 
millimetres.  The  prostatic  portion  can  be  distended 
to    13-15    millimetres.      Clinicians,    for    pronounced 


if 

Fig.   1. 

Diagrammatic  representation  of  the  curves  and  dilatations 

of  the  uretlira. 

pathological  and  physiological  reasons,  as  will  be 
shown  later,  divide  the  urethra  into  anterior  and 
posterior  regions,  the  anterior  being  the  penile  or 
spongy  portion,  and  the  posterior  including  the 
membranous  and  prostatic  portions. 

The  anterior  urethra,  the  spongy  portion,  is  about 
six  inches  in  length  and  is  buried  in  the  corpus 
spongiosum  (corpus  cavernosum  urethrce).  It  begins 
at  the  meatus  and  ends  with  the  bulb,  beyond  which 
it  is  normally  shut  ofi  from  the  posterior  urethra  by 


44    GONORRHCEA  &  ITS  COMPLICATIONS 


the    tonic    contraction    of    the    compressor    urethrse 
muscle.      Reference  to  Figure  2  will  show  the  reason 


K 


Fig.   2. 
Male  Pelvis  in  Mediax  Section. 


A.- — Suspensory  ligament  of  penis. 
B. — Pendulous  urethra. 
C. — Bulbous  urethra. 
U.  —  Cowper's  gland. 


E. — Membranous  urethra. 
F. — Prostate  gland. 
G. — Prostatic  urethra. 
H. —  Ejaculatory  duct. 


I. — Seminal  vesicle. 

for  a  further  subdivision  of  the  anterior  urethra 
into  pendulous  and  fixed  sections,  the  dividing  line 
being  at  the  suspensory  ligament.  The  pendulous 
portion  will  drain  towards  the  meatus,  but  in  the 
perineal    portion    discharge    will    only    "  overflow  " 


URETHRITIS    IN   THE   MALE 


towards  the  meatus  when  the 
retaining  capacity  of  this  sec- 
tion of  the  canal  is  exhausted. 

Numerous  minute  openings 
pierce  the  Hning  membrane  of 
the  anterior  urethra.  These  are 
the  ducts  of  racemose  mucous 
glands  and  follicles  known  as 
the  glands  of  Littre  (Figs.  3  and 
4).  These  ducts  have  an  oblique 
inclination  towards  the  meatus, 
as  have  also  the  ducts  of  Cowper's 
glands,  which  enter  the  floor  of 
the  canal  at  the  anterior  end  of 
the  bulbous  region.  Many  larger 
recesses,  the  lacunae  of  Morgagni, 
are  also  found,  principally  along 
the  roof  and  lateral  walls  of 
the  urethra.  The  Lacuna  Magna 
(Fig.  5)  is  a  specially  important 
and  conspicuous  recess  situated 
on  the  upper  surface  of  the  fossa 
navicularis.  All  these  lacunas,  like 
the  glands  of  Littre,  have  their 
openings  directed  forward. 

The  mucous  membrane  of  the 
anterior  urethra  is  lined  by  a 
delicate  epithelium,  the  super- 
ficial cells  of  which  are  long 
and  columnar  except  over  the 
first  5  to  8  millimetres  in  the 
fossa  navicularis,  where  they  are 
squamous  and  where  the  sub- 
jacent membrane  is  beset  with 
papillae. 


y-^'^i 


■M: 


Fig.  3. 
Showing  roof  of  the  urethra, 
with    bristles    passed   into 
Littre's  follicles.    (Taylor.) 


46    GONORRHCBA  &  ITS  COMPLICATIONS 

The  posterior  urethra  includes  the  membranous 
and  prostatic  portions.  The  membranous  portion  is 
one-half  to  three-fourths  of  an  inch  long  directed 
upwards  and  backwards  within  the  layers  of  the 
triangular  ligament,  and  is  separated  from  the  pubis 


Fig.  4. 

Microscopic  section  of  one  of  the  mucous  glands  or  follicles  of  Littre'  open- 
ing into  the  lumen  of  the  urethra  :  .r  y,  lateral  branches  of  main  duct^  with 
their  most  superficially  situated  acini  ;  z  z,  continuation  of  main  duct,  with 
deeply  seated  acini ;  s  s,  trabecular  of  the  cavernous  tissue ;  w  w,  tunica 
albuginea.     (Taylor.) 


by  an  interval  of  one  inch.  It  is  surrounded  by  a 
layer  of  unstriped  muscle  and  also  by  the  fibres  of  the 
compressor  urethrse  muscle  (Fig.  6).  As  already 
mentioned,  it  is,  with  the  exception  of  the  meatus, 
the  narrowest  part  of  the  canal.  The  membranous 
portion  is  the  least  vascular  section  of  the  urethra, 


URETHRITIS   IN  THE  MALE 


47 


and  its  covering  is  simple 
columnar  epithelium.  Cowper's 
glands  lie  between  the  la^^ers 
of  the  triangular  ligament  in 
close  contact  with  the  mem- 
branous urethra. 

The  prostatic  portion  has  many 
important  structures  and  connec- 
tions. It  is  one  and  a  quarter 
inches  long,  and  its  direction  is 
nearly  vertical  with  a  slight 
backward  curve.  Although  sur- 
rounded by  the  prostate,  it  is 
easily  distensible  up  to  a  dia- 
meter   of    half    an    inch    in    its 

'A A]      +1   *    A  Showing  the  lacuna  magna 

middle  thud.  ^  ^  and  a  deeper  valve-like  pocket 

A    narrow    median    ridge,    the  or  crypt,  and  the  orifices  of 
crista     urethrte,     originating     in  n^^^erous  mucous  glands  or 

'  ^  ®  crvpts.     (Taylor.) 

the  posterior  part   of  the  mem- 
branous   urethra,    runs    backward    along    the    floor 
and  terminates  in  the   colliculus  seminalis  or  veru- 


FiG.  G. 
Transverse  section  of  the  membranous  urethra^  showing  its  anatomical 
structure:  1,  lumen  of  canal ;  2,  mucous  membrane  with  circumambient 
connective  tissue  ;  3,  vascular  layer  ;  4,  longitudinal  muscular  fibres  ;  5, 
circular  muscular  fibres  composing  the  external  sphincter  of  the  urethra. 
(Taylor,  after  Testut.) 


48    GONORRHCEA  k  ITS  COMPLICATIONS 


montanum.  This  crest  is  three-quarters  of  an 
inch  long  and  projects  rather  more  than  one- 
eighth  of  an  inch  at  its  highest  point.  It 
consists    for    the    most    part    of    cavernous    tissue. 


^v 


Fig,   7. 
Floor  of  urethra  and  base  of  bladder. 


In  the  grooves  on  each  side  of  this  ridge  are 
seen  the  numerous  openings  of  the  prostatic  ducts 
from  which  a  viscid  fluid  oozes  on  pressure.  On  the 
summit  of  the  ridge  or  on  its  anterior  dcesending 


URETHRITIS   IN  THE  MALE 


49 


face  is  placed  the  entrance  to  the  sinus  pocularis,  a 
pear-shaped  pouch  which  penetrates  the  prostate 
gland  for  about  one-quarter  of  an  inch  or  more 
(6  to  12  millimetres).  It  is  the  homologue  of  the 
uterus  and  vagina,  and  is  lined  with  mucous  mem- 
brane and  surrounded  by  a  circular  muscular  coat. 
The  orifice  in  its  typical  form  is  a  longitudinal  cleft. 


Fig.  8. 

Fig.    9. 

Fig.  10. 

Section  through  the  pre- 

Just behind  the 

Through  the  prepuce  at 

puce  and  glans. 

meatus. 

base  of  glans. 

Fig.   11. 
Through  prepuce  and 
corona  glandis. 


Fig.   12.  Fig.   13. 

Sections  just  behind  the  corona  glandis^  spongy 

and  cavernous  bodies  well  shown.    (Taylor.) 


2-3  millimetres  long,  and  on  or  near  its  lips  are  the 
openings  of  the  common  seminal  or  ejaculatory  ducts. 
The  mucous  membrane  of  the  prostatic  portion 
of  the  urethra  is  covered  by  a  laminated  epithelium 
like  that  of  the  bladder.  The  sinus  pocularis  is  lined 
by  a  columnar,  and  according  to  some  authorities, 
ciliated    epithelium    pierced    by    numbers    of    small 


WATSON. 


50    GONORRHCEA  &  ITS  COMPLICATIONS 


Fig.  14. 


Fig.  15. 


Fig.   16. 


Fig.   17. 


Fig.  18.  Fig.  19. 

Figs.  1-4  to  19  show  sections  from  before  backward  through  the  penile 
urethra.  The  pectiniform  septum  is  complete  except  Fig.  15,  where  corpora 
cavernosa  are  continuous  with  one  another.     (Taylor. ) 


Fig.  20. 

Through  bulbomembranous  junction, 
urethra  surrounded  by  some  an- 
terior fibres  of  the  compressor. 


Fig.  21. 

Through  apex  of  prostate. 

(Taylor.) 


URETHRITIS   IN  THE  MALE 


51 


convoluted  glands.  In  the  posterior  urethra  the 
erectile  tissue  is  scanty,  while  the  muscular  coat  is  well 
developed. 

The  striated  and  unstriated  musculature  of  the  urethra. 
— Close  to  the  vesical  insertion  of  the  urethra  and 
under  cover  of  the  prostate  there  is  a  circular  bundle 
of  unstriped  muscular  fibres  mixed  with  elastic  fibres, 


Fig.    22. 
Showing  the  position  of  the  ejaculatory  ducts  in  the  middle  of  the  prostate 
under  the  verumontanum  just  before  they  turn  upward  and  end  in  the  pros- 
tatic urethra.     The  capsule  of  the  prostate  is  well  shown.     (Taylor.) 


Fig.   23. 
Showing  the  position  of  the  ejaculatory  ducts  in  the  lower  part  of  the 
prostate  and  behind  the  urethra  :  1^  vesical  orifice  of  the  urethra  ;  2,  ejacu- 
latory ducts.     (Taylor.) 


to  which  the  name  of  internal  prostatic  or  vesical 
sphincter  has  been  given.  Towards  the  apex  of  the 
prostate  there  is  another  grouping  of  unstriped  fibres 
which,  together  with  some  striped  fibres  of  the  com- 
pressor urethrae,  form  the  external  prostatic  sphincter. 
The  membranous  portion  of  the  urethra  is  surrounded 
by  both  striated  and  plain  muscle  fibres,  the  former 
belonging  to  the  compressor  urethras  muscle. 


52    GONORRHCEA  &  ITS  COMPLICATIONS 

There  is  thus  a  triple  arrangement  of  sphincters  in 
the  posterior  urethra,  and  considerable  difference  of 
opinion  has  been  expressed  as  to  their  relative 
strength  and  their  functions.  Finger  enunciated  the 
theory  that  the  internal  sphincter  close  to  the  bladder 
was  only  of  sufficient  power  to  retain  a  small  quantity 
of  urine  in  the  bladder,  and  that  as  the  urine  accumu- 
lated the  posterior  urethra  became  merged  into  the 
bladder,  forming  a  funnel-shaped  "  neck."  He  at- 
tributed real  power  of  retention  to  the  combined 
action  of  the  musculature  of  the  membranous  portion 
of  the  urethra.  This  view  is  supported  by  some 
experimental  and  clinical  evidence  which  merits  con- 
sideration. Thus  it  is  asserted  that  the  urethra  is 
shortened  when  the  bladder  is  full,  and  that  a  catheter 
at  a  depth  of  16-19  centimetres  will  tap  the  urine, 
as  against  a  passage  of  18-21  centimetres  required  to 
reach  the  interior  of  the  bladder.  This  difference  of 
2  centimetres  indicates,  according  to  Finger,  that  to 
this  extent  the  prostatic  urethra  has  been  merged 
into  the  cavity  of  the  bladder.  A  possible  explana- 
tion of  this  shortening  of  the  posterior  urethra,  how- 
ever, may  be  found  in  the  suggestion  that  the  longi- 
tudinal uustriped  muscle  fibres  contract  when  the 
bladder  is  distended  for  the  purpose  of  re-enforcing 
and  combining  the  action  of  all  the  circular  fibres  to 
ensure  complete  control  of  the  urine.  The  shortening 
could  also  be  contributed  to  by  the  downward  pres- 
sure of  the  heavy  bladder. 

Finger  quotes  some  experiments  conducted  by 
Born,  who  injected  plaster  of  Paris  into  the  bladders 
of  recently  killed  animals,  and  found  that  when  a 
small  quantity  y\'as  used  the  plaster  cast  had  an  ovoid 
form  and  was  sharply  defined  from  the  urethra  by  the 
action  of  the  internal  sphincter.     When  a  quantity 


URETHRITIS   IN  THE   MALE  53 

sufficient  to  distend  the  bladder  was  inserted  the  east 
was  pear-shaped,  owing  to  the  absorption  of  the 
prostatic  urethra  into  the  bladder  to  form  one  vesico- 
prostatic  chamber,  the  prostatic  portion  forming,  of 
course,  the  apex  of  the  cone. 

Leedham-Green  successfully  controverts  the  re- 
sults of  these  experiments  ("  British  Medical  Journal," 
August,  1906),  which  he  discounts  as  having  been  con- 
ducted on  dead  animals  in  conditions  so  unlike  those 
obtaining  in  man  during  life  as  to  be  valueless.  Wlien, 
on  the  other  hand,  he  injected  a  suspension  of  bismuth 
into  the  bladders  of  certain  men  and  youths,  he  found 
that  the  radiograph  in  each  case,  whether  the  bladder 
had  been  fully  distended  or  not,  was  oval  and  not 
pear-shaped,  and  that  the  urethra  was  sharply  cut 
off  from  the  bladder  without  a  suggestion  of  bladder 
neck. 

Comparison  with  the  anatomical  arrangement  in 
the  female,  in  my  opinion,  finally  disposes  of  this 
widely-taught  theory. 

Another  point  of  much  importance  concerns  the 
strength  and  utility  of  the  sphincter  action  of  the 
muscles  surrounding  the  membranous  urethra,  and 
said  to  shut  off  the  posterior  urethra  from  the  an- 
terior. Extreme  views  have  been  advocated  on  both 
sides,  and  each  contains  some  elements  of  truth.  I 
think  that  it  is  advisable,  however,  to  emphasise  the 
danger  of  placing  too  much  reliance  on  the  security  of 
this  barrier.  It  is  probable  that  in  most  cases  the 
contraction  is  sufficient  to  prevent  the  immediate 
ingress  of  injected  ffiiids  unless  considerable  pressure 
is  applied,  but  continued  pressure  will  overcome  the 
resistance  in  all  cases. 

The  injection  of  an  irritating  fluid  into  an  inflamed 
urethra  excites  marked  contraction  and  even  spasm, 


54    GONORRHCEA  &  ITS  COMPLICATIONS 

especially  in  patients  of  a  nervous  temperament. 
On  the  other  hand,  the  use  of  bland  fluids  at  a  suit- 
able temperature  helps  to  allay  the  tendency  to  con- 
traction, and  when  employing  local  anaesthetics  the 
risk  of  abolishing  this  reflex  should  not  be  over- 
looked. There  is  considerable  individual  variation 
as  regards  the  resistance  offered.  In  washing  out  the 
urethra  according  to  Janet's  method,  the  anterior 
urethra  is  first  irrigated  at  a  low  pressure,  and  there- 
after the  pressure  is  increased  until  the  fluid  enters  the 
posterior  urethra  and  bladder.  The  voluntary  efforts 
of  the  patient  to  relax  the  compressor  urethrae  are 
an  aid  in  most  cases.  That  in  practically  all  cases 
this  procedure  is  possible  proves  the  fallibility  of  the 
sphincter  as  a  guard  against  the  invasion  of  the 
posterior  urethra  by  an  injection  in  the  hands  of  a 
strenuous  patient.  Patients  are  frequently  told  to 
fill  the  urethra  to  its  fullest  capacity,  to  retain  the 
solution  for  ten  to  fifteen  minutes,  and  at  the  same 
time  to  massage  the  penis  with  a  view  to  ingratiating 
the  injection  into  all  the  crevices.  In  many,  if  not  all, 
of  such  cases,  a  portion  of  the  injection  will  find  its 
way  into  the  posterior  urethra  with  unfortunate  re- 
sults. In  the  use  of  soluble  bougies  there  is  also  a 
distinct  risk  of  the  posterior  urethra  being  entered, 
especially  if  one  is  inserted  at  bedtime.  Sufficient 
has  meantime  been  said  to  show  that  care  has  to  be 
exercised  in  applying  local  treatment  which  it  is 
desired  to  limit  to  the  anterior  urethra.  The  capacity 
of  the  anterior  urethra  in  the  average  man  is  from 
8-14  cubic  centimetres. 

The  compressor  urethrae  being  composed  of  striated 
fibres  is  a  voluntary  muscle,  but  its  action  is  mainly 
a  reflex  one,  and  it  is  not  sufficiently  under  the  con- 
trol  of  the   will   to   ensure   a   successful   closure   on 


URETHRITIS   IN  THE  MALE  55 

demand.  Its  tonic  contraction,  however,  will  aid  the 
unstriped  circular  fibres  in  occluding  the  membranous 
urethra. 

Whether  secretions  can  escape  from  the  posterior 
urethra  through  this  sphincter  is  another  debated 
point.  Finger,  Scholtz,  and  others  inaintained  that 
the  external  sphincter  is  an  absolute  check  to  the 
passage  of  secretions,  blood,  etc.,  from  the  posterior 
urethra  so  as  to  appear  as  an  external  discharge. 
They  hold,  on  the  contrary,  that  such  discharge 
always  passes  backward  into  the  bladder.  It  is 
generally  admitted  that  this  is  in  accord  with  most 
clinical  observations.  The  probable  explanation  is 
that  the  combined  strength  of  the  external  sphincter 
and  the  compressor  urethrse  is  greater  than  that  of 
the  internal  sphincter,  and  that  fluids  in  the  posterior 
urethra  seeking  the  direction  of  least  resistance  find 
their  way  into  the  bladder. 


THE    DISTRIBUTION    OF   THE    GONOCOCCUS    IN 
THE   MALE   URETHRA 

Gonococcal  growth  is  spread  throughout  the 
urethra  by  the  action  of  several  agencies.  In  the 
first  place,  direct  colony  extension  by  subdivision  of 
the  organism,  as  in  a  culture  tube,  is  in  constant 
progress.  But  were  this  the  only  method  of  propaga- 
tion, several  weeks  must  elapse  ere  the  bulb  and  the 
entrance  to  the  posterior  urethra  could  be  reached. 
Rapid  extension  is  due  to  the  deposition  of  new 
colonies  from  the  collection  of  infected  pus  which 
gathers  in  the  urethra  when  closure  of  the  meatus  by 
dried  secretion  or  dressings  delays  or  prevents  the 
escape  of  the  discharge.  Another  factor  in  the  up- 
ward extension  doubtless  is  the  suction  action  already 


56    GONORRHCEA  k  ITS  COMPLICATIONS 

referred  to  which  follows  seminal  emission  or  urina- 
tion. A  consideration  of  these  points  suggests  the 
necessity  for  free  and  uninterrupted  draining  day 
and  night,  the  avoidance  of  any  arrangement  of 
suspensories  or  dressings  which  would  interfere  with 
the  pendulous  position  of  the  penis,  and  possibly 
the  use  of  some  form  of  slight  constricting  band 
above  the  area  of  infection.  Further  consideration 
of  these  points  will  arise  again  in  connection  with 
treatment. 

Extension  to  the  posterior  urethra  is  delayed  and 
in  many  cases  prevented  by  the  tonic  contraction 
of  the  circular  muscular  fibres,  striped  and  unstriped, 
which  surround  the  membranous  urethra,  so  that  in 
about  30  per  cent  of  untreated  cases,  and  in  a  much 
larger  percentage  of  suitably  treated  cases,  the 
gonorrhoea  is  limited  to  the  anterior  urethra,  not  only 
in  the  initial  stages,  but  throughout  its  whole  course. 

This  closure  of  the  first  portion  of  the  posterior 
urethra  is,  as  has  already  been  pointed  out,  not 
sufficient  to  prevent  the  backward  passage  of  gono- 
cocci  whether  conveyed  by  fluids,  instruments,  or 
growth  of  colonies,  but  the  membranous  portion 
presents  in  normal  conditions  a  much  less  favourable 
medium  for  the  successful  deposition  and  growth  of 
colonies  than  the  other  parts  of  the  urethral  canal. 
When  posterior  urethritis  appears,  it  usually  begins 
in  the  prostatic  portion,  and  invasion  of  the  mem- 
branous mucosa  is  secondary  to  that  of  the  prostatic. 
All  the  conditions  helpful  to  the  activity  of  the 
gonococcus  prevail  in  the  prostatic  area,  but  many 
of  them  are  wanting  in  the  membranous.  Thus  the 
normal  contracted  condition  of  the  canal  in  prevent- 
ing the  collection  of  discharge  with  its  resulting  irri- 
tation is  a  most  important  factor  in  the  comparative 


URETHRITIS   IN  THE   MALE  57 

immunity  of  the  membranous  mucosa  to  invasion 
from  below.  When  the  prostatic  urethra  is  ah-eady 
involved,  this  freedom  from  gonotoxine  irritation  does 
not  obtain  to  the  same  extent,  for  although  the 
discharge  in  the  posterior  urethritis  escapes  back- 
ward into  the  bladder,  it  only  does  so  when  the 
prostatic  portion  is  dilated  by  the  pressure  of  the 
collecting  pus,  and  a  force  sufficient  to  overcome  the 
internal  prostatic  sphincter  of  the  bladder  accrues 
therefrom.  During  the  accumulation  of  this  pus 
there  will  be  an  ever-increasing  and  spreading  irri- 
tation of  the  upper  region  of  the  membranous  urethra, 
and  after  every  micturition  the  mucous  membrane 
will  be  left  moist  with  a  gonotoxic  urine. 

In  no  case,  however,  does  the  membranous  portion 
suffer  from  such  acute  or  prolonged  infections  as  the 
other  parts  of  the  urethra.  The  nature  of  its  epi- 
thelium and  its  comparative  freedom  from  glands  and 
culs-de-sac  is  largely  responsible  for  this  resisting 
power. 

On  the  other  hand,  the  prostatic  urethra  is  sus- 
ceptible to  acute  inflammations,  and  its  numerous 
glands  and  ducts  form  happy  hunting  grounds  for  the 
future  life  of  the  gonococcus. 


ACUTE  ANTERIOR   GONOCOCCAL   URETHRITIS 

Acute  anterior  gonorrhoeal  urethritis  in  the  male  is 
most  suitably  described  as  developing  in  three  stages, 
and  this  is  quite  in  accord  with  the  clinical  course 
of  the  disease,  although  the  stages  are  by  no  means 
sharply  defined,  but  merge  imperceptibly  from  one 
to  the  other.  These  stages  are  (a)  the  mucous,  initial, 
or  prodromal  stage  ;  [b]  the  purulent  or  middle  stage  ; 
(c)  the  resolving  or  terminal  stage. 


58    GONORRHCEA  &  ITS  COMPLICATIONS 

There  are  also  three  principal  types.  In  the  first, 
the  disease  runs  a  mild  course  with  the  symptoms 
but  slightly  marked ;  the  second  is  the  common 
acute  form  ;  the  third  includes  those  cases  in  which 
the  inflammation  is  hyperacute  and  the  symptoms 
correspondingly  violent. 

In  the  first  place,  a  description  of  an  ordinary  acute 
gonorrhoea  in  its  three  stages  will  be  submitted,  and 
following  that  the  appearances  shown  by  the  mild  and 
severe  types  will  be  considered. 

The  mucous  stage. — When  a  man  knows  that  he  has 
subjected  himself  to  the  risk  of  infection  and  is 
anxious  as  to  the  result,  he  will  be  keenly  sensitive 
to  the  slightest  feeling  of  irritation.  The  first  evi- 
dence he  will  have  of  the  onset  of  the  disease  will  be 
a  slight  sensation  of  heat  and  tingling  within  the 
meatus,  most  marked  whilst  urinating.  In  a  short 
time  it  will  be  possible  to  express  from  the  urethra 
a  small  quantity  of  thin  glairy  mucus.  If  the  meatus 
be  examined  at  this  period,  a  commencing  redness 
of  the  mucous  membrane  will  be  noticed. 

The  subjective  symptoms  may  be  so  trifling  as  to 
be  entirely  overlooked  by  the  patient,  but  if  he  allows 
the  slight  inflammatory  reaction  to  excite  him  to 
further  excesses,  the  more  acute  symptoms  will  be 
precipitated. 

Microscopic  examination  of  the  secretion  in  this 
stage  shows,  in  addition  to  mucus  and  epithelial 
cells,  a  variable  but  usually  small  number  of  poly- 
nuclear  leucocytes  and  numerous,  mostly  extracellar, 
gonococci,  many  of  which  will  be  found  adhering  to 
epithelial  cells.  The  appearances  shown  by  the 
smear  depend  largely  on  the  manner  in  which  it 
has  been  obtained,  i.e.,  by  platinum  loop,  spoon, 
or  swab. 


URETHRITIS   IN  THE  MALE  59 

The  swab  is  the  most  satisfactory  method  in  this 
stage,  as  it  is  also  in  chronic  conditions.  Gonococci 
are  Ufted  from  the  epithehal  surface  and  appear  in 
the  smear  in  greater  numbers,  so  simphfying  the 
diagnosis.  A  small  quantity  of  sterile  wool  is  wrapped 
round  a  thin  ball-pointed  probe,  and  after  the  meatus 
has  been  cleansed,  the  probe  is  carefully  inserted  for 
about  an  inch  and  gently  rotated.  On  transferring 
the  material  so  obtained  to  the  slide,  care  should  be 
taken  to  spread  the  smear  with  uniform  thinness. 
Staining  by  Gram's  method  is  essential  for  dif- 
ferentiating the  gonococcus,  but  for  examination  of 
the  cells  other  methods  are  applicable. 

The  purulent  stage  is  usually  established  by  the 
second  or  third  day.  The  character  of  the  discharge 
changes  from  mucous  to  white,  milky  muco-pus. 
This  soon  becomes  thicker  and  creamy  yellow,  and  by 
the  beginning  of  the  second  week  a  greenish  tinge, 
due  to  admixture  Avith  a  minute  quantity  of  blood,  is 
usually  evident  in  the  discharge.  It  is  copious 
in  quantity  and  constant  in  its  flow,  but  is  subject  to 
some  increase  at  night.  Examination  of  the  urine 
by  Thompson's  two-glass  method  may  demonstrate 
even  more  clearly  than  a  scrutiny  of  the  meatus  and 
clothing  the  amount  of  pus  which  is  being  excreted. 

Ectropion  is  produced  by  e version  of  the  "  angry  " 
red  mucosa  at  the  meatus.  The  irritation  of  the 
glans  causes  it  to  appear  red,  turgid,  and  swollen. 
The  inflammation  spreads  along  the  froenum  to  the 
prepuce,  and  the  resulting  oedema  may  give  rise  to 
either  phimosis  or  paraphimosis,  according  to  the 
length  and  position  of  the  prepuce.  The  whole  penis 
becomes  swollen,  hot,  and  tender.  Lymphatic  vessels 
may  appear  in  the  skin  as  red  streaks  and  the  inguinal 
glands  may  be  enlarged  and  painful,  but  suppuration 


60    GONORKHCEA  &  ITS  COMPLlCATIO^'S 

does  not  usually  supervene.  The  urine  is  discharged 
in  a  small  stream,  partly  on  account  of  the  engorged 
and  swollen  condition  of  the  mucous  membrane,  and 
partly  from  reflex  as  well  as  conscious  retardation  in 
the  attempt  to  minimise  the  pain  caused  by  the 
passage  of  the  acid  urine  over  the  inflamed  surface. 
The  scalding  pain  experienced  on  passing  urine, 
"  ardor  urinae,"  is  the  most  distressing  of  the  subjec- 
tive symptoms.  During  the  height  of  the  inflamma- 
tion it  is  so  severe  that  the  patient  dreads  the  necessity 
for  micturition,  and  the  bladder  is  emptied  as  slowly 
as  possible  to  avoid  distension  of  the  exquisitely  ten- 
der urethra.  Pain  at  first  is  limited  to  the  times  of 
urination  and  a  few  succeeding  minutes,  but  later  it 
is  more  or  less  continuous.  It  may  be  felt  along  the 
whole  anterior  urethra,  but  it  is  usually  most  marked 
at  the  fossa-navicularis  and  at  the  bulb.  It  is  in- 
creased by  pressure  on  the  bulb,  e.g.,  during 
exertion  and  during  sitting.  Pain  in  the  back  is  also 
common. 

Another  troublesome  symptom  is  the  occurrence 
of  painful  erections.  These  are  most  frequent  at 
night,  and  cause  great  discomfort  both  on  account  of 
the  accompanying  pain  and  the  interruption  of  sleep. 
The  pain  is  due  to  the  tension  on  the  urethra  and  its 
surrounding  area  of  corpus  spongiosum  involved  in 
the  inflammatory  process. 

In  spite  of  the  severity  of  the  local  symptoms,  the 
constitutional  symptoms  are  comparatively  trifling. 
Apart  from  pallor,  decreased  appetite,  and  feeling  of 
malaise,  there  is  little  evidence  of  any  disturbance  of 
the  ordinary  health. 

The  inflammation  reaches  its  height  usually  by  the 
end  of  the  second  week,  and  during  the  third  week  the 
symptoms  are  maintained  with  but  little  remission 


PLATE  VII. 


Film  of  pus  showing  Gonococci  (stained  Gram  and  counterstained  1  in  10  Carbol-Fuchsin). 


URETHRITIS   IN   THE  MALE  61 

from  the  acute  level,  but  thereafter  in  favourable 
cases  the  resolving  or  terminal  stage  begins. 

Microscopic  appearance  of  the  discharge  in  the  puru- 
lent stage. — A  drop  of  the  discharge  may  be  obtained 
from  the  meatus  after  external  cleansing  by  direct 
contact  with  the  slide.  The  end  of  the  slide  should 
be  chosen  for  this  purpose,  and  the  pus  is  spread  by 
drawing  the  edge  of  another  slide  held  at  an  oblique 
angle  along  the  whole  length  of  the  smear  slide  as  in 
making  a  blood  preparation.  This  gives  an  equal  and 
thin  distribution  of  the  material. 

With  the  platinum  loop  it  is  difficult  to  spread  the 
pus  with  a  sufficiently  thin  and  even  smear.  The 
cotton-wool  swab  is  more  satisfactory,  but  with  its 
use  the  number  of  extracellular  gonococci  is  increased, 
while  intracellular  gonococci  are  diminished. 

On  examination  with  an  oil  immersion  lens  great 
numbers  of  polynuclear  leucocytes  are  seen,  many  of 
them  containing  gonococci  in  pairs  or  groups.  It  is 
remarkable  how  little  deleterious  effect  seems  to  be 
produced  on  the  leucocytes  by  the  ingested  gonococci  ; 
their  staining  properties  are  unimpaired,  no  signs  of 
degeneration  being  evident.  The  same  is  true  regard- 
the  action  of  the  leucocytes  on  the  gonococci ;  their 
activity  is  not  interfered  with  by  absorption  into  the 
leucocytes,  in  fact  they  are  said  to  multiply  in  this 
position.  Some  cells  are  crammed  with  organisms, 
yet  both  the  cell  structures  and  the  cocci  stain 
beautifully.' 

Discharge  which  has  been  retained  in  the  urethra 
for  some  little  time  shows  a  larger  number  of  in- 
tracellular gonococci  than  pus  expressed  after  cleans- 
ing the  urethra. 

Epithelial  cells  are  few  or  absent.  The  few  that 
may  be  present  are  not  like  the  large  lamellar  cells 


62    GONORRHCEA  &  ITS  COMPLICATIONS 

found  in  the  mueous  stage,  but  smaller,  oval,  transi- 
tional forms.  A  varying  number  of  eosinophile  cells 
have  been  shown  to  be  present.  These  are  scanty  in 
the  first  two  weeks,  but  increase  later,  especially  if  the 
posterior  urethra  become  involved.  Mast  cells  and 
mononuclear  lymphocytes  are,  in  addition,  found  in 
the  late  phase  of  this  stage. 

That  phagocytosis  occurs  is  evident,  as  the  gono- 
coccus  itself  has  no  power  of  movement,  and  therefore 
no  power  to  penetrate  the  leucocyte.  In  fact,  an 
active  phagocytosis  can  be  seen  in  progress  on  making 
an  artificial  mixture  of  fresh  human  pus,  serum  bullion, 
and  gonococci.  Phagocytosis  is  most  active  in  the 
lumen  of  the  lu'cthra.  That  it  also  occurs  to  a  small 
extent  in  the  submucous  tissue  can  be  proved  by 
examining  stained  sections. 

The  resolving,  declining,  or  terminal  stage  is  the 
period  during  which  the  inflammator}^  symptoms 
subside.  In  a  case  which  is  running  a  satisfactory 
course,  the  terminal  stage  may  be  expected  to  assert 
itself  in  the  fourth  week,  and  to  terminate  in  the 
disappearance  of  all  subjective  symptoms  after  a 
period  of  retrogression  lasting  two  to  three  weeks. 
There  is,  however,  no  dividing  line  between  the 
purulent  and  the  declining  stages.  They  merge 
imperceptibly  into  one  another  over  an  intermediary 
period  of  several  daj^s.  The  discharge  gradually 
decreases  in  quantity  and  purulence,  until  it  becomes 
scanty  and  muco-purulent,  and  finally  only  appears 
as  shreds  in  the  first  volume  of  urine  and  a  trace  of 
hypersecretion  evident  only  in  the  morning.  Ulti- 
mately the  secretion  becomes  normal,  with  no  evidence 
whatever  of  any  excess. 

All  other  symptoms  are,  before  the  onset  of  the 
terminal  stage,   much  reduced  in  severity,   and  the 


URETHRITIS  IN  THE  MALE  63 

patient  in  the  last  stage  suffers  little  inconvenience, 
apart  from  that  necessarily  associated  with  the 
continuance  of  any  discharge.  There  is  now  no  dis- 
tress on  inicturition,  and  erections,  although  annoying 
and  excessive,  are  not  painful  and  the  sleep  is  not 
disturbed. 

At  any  time  in  the  course  of  the  declining  stage  a 
relapse  may  occur.  A  reason  for  the  recrudescence 
may  be  elicited  from  the  patient  in  an  admission  of  a 
departure  from  the  path  of  rectitude  either  as  regards 
venery  or  alcohol ;  or  it  may  be  attributable  to  excess 
in  eating  or  to  physical  exertion. 

Microscopic  appearance  of  the  discharge  in  the 
terminal  stage. — Mucus  makes  its  reappearance,  and 
the  purulent  characteristics  become  proportionately 
lessened.  Epithelial  cells,  some  of  which  contain 
keratin  granules,  appear  in  increasing  numbers. 
Gonococci  are  more  sparsely  distributed  and  finally 
are  difficult  to  find  in  the  discharge. 

In  the  foregoing  account  of  the  moderate  tj^pe  of 
gonococcal  inflammation,  it  is  understood  that  the 
description  applies  only  to  untreated  and  uncom- 
plicated cases.  The  modifying  influence  of  treatment 
and  the  effects  of  complications  and  exacerbations 
will  be  considered  in  their  respective  chapters. 


THE  SUBACUTE   OR    MILD   TYPE    OF   GONOCOCCAL 
URETHRITIS 

In  this  class  of  case  the  symptoms  of  the  mucous 
stage  may  continue  with  but  little  evidence  of  a 
purulent  phase,  either  as  regards  the  discharge  or 
other  symptoms  of  acute  inflammation.  Such  cases 
are  difficult  to  distinguish  from  those  of  a  "  simple 


64    GONORRHCEA  &  ITS  COMPLICATIONS 

urethritis,"  and  in  fact  the  diagnosis  is  determined 
only  by  demonstrating  the  presence  of  the  gono- 
coccus  in  smears  and  cultures  taken  from  the 
urethra.  The  possibility  of  the  organism  being  the 
micrococcus  catarrhalis  must  be  kept  in  view. 

All  urethras  are  not  equally  sensitive  to  the 
products  of  gonococcal  activity.  Some  individuals 
may  harbour  gonococci  without  symptoms  of  in- 
flammation being  present.  As  a  rule,  when  a  positive 
result  follows  the  search  for  the  gonococcus,  whether 
undertaken  for  medico-legal  or  other  purposes,  a 
history  of  a  previous  acute  attack  of  gonorrhoea  will 
be  obtained,  and  the  presence  of  the  gonococcus  is  due 
to  the  chronic  infection  of  a  para-urethral  passage, 
gland,  or  cul-de-sac  in  the  anterior  urethra  or  of  some 
structure  in  the  posterior  urethra.  But  occasionally 
a  case  will  be  encountered  where  no  history  of  previous 
gonorrhoea  can  be  obtained,  and  where  there  is  no 
evidence  of  chronic  inflammation,  yet  gonococci  are 
present  in  the  urethra.  If  the  patient  is  a  married 
man  his  wife  may  be  found  to  be  infected,  and  this 
may  be  the  source  of  repeated  reinoculation  with 
gonococci.  Thus  his  infectivity,  which  otherwise 
would  probably  be  determinate,  is  indefinitely  main- 
tained. How  long  the  gonococcus  would  survive, 
without  reimplantation,  in  the  urethra  of  a  non- 
susceptible  carrier  it  is  impossible  to  say.  One 
cannot  draw  accurate  conclusions  from  the  small 
number  of  cases  and  experiments  at  present  available 
for  consideration. 

The   influence   which   prevents   the   inflammatory 

reaction  to  the  gonococcus  may  have  either  a  local  or 

'  a  constitutional  origin.     Thus  it  may  be  due  to  the 

resistant  properties  of    the  urethral    epithelium,    or 

there  may  be  in  the  blood  a  substance  in  the  nature 


URETHRITIS   IN  THE  MALE  65 

of  an  antibody  which  inhibits  the  fertiUty  of  the 
organism.  The  former  is  the  more  probable  explana- 
tion of  these  cases.  Variation  in  the  virulence  of 
different  strains  of  gonococci  plays  no  role  in  this 
connection. 

All  gradations  from  the  case  of  a  non-susceptible 
carrier  to  a  case  of  gonorrhoea  with  the  usual  symp- 
toms, only  in  lessened  degree  as  regards  acuteness 
and  duration,  may  be  classified  as  belonging  to  the 
mild  type  of  gonorrhoeal  infection. 


THE    HYPERACUTE  TYPE   OF    ANTERIOR    GONOCOCCAL 
URETHRITIS   AND    ITS  LOCAL   COMPLICATIONS 

In  from  10  to  20  per  cent  of  all  cases,  owing  to  a 
general  or  local  susceptibility  of  the  patient,  or  to 
injudicious  habits  or  treatment,  the  inflammatory 
reaction  is  exceptionally  acute,  and  the  symptoms 
show  a  corresponding  excess  in  their  severity.  In 
such  cases,  resolution  is  delayed  and  complica- 
tions are  frequent.  On  account  of  the  severity 
of  the  suffering  and  continued  loss  of  sleep, 
the  general  health  is  markedly  involved.  All  the 
symptoms  already  enumerated  are  exaggerated ; 
ectropion  of  the  urethral  mucous  membrane  is  pro- 
nounced ;  the  discharge  is  distinctly  greenish  or  even 
haemorrhagic,  and  oedema  spreads  from  the  prepuce 
to  the  penis,  which  is  considerably  swollen  and  very 
tender.  The  passage  of  urine  is  attended  with 
agonising  pain  ;  the  stream  is  thready,  corkscrew, 
forked,  and  interrupted,  or  discharged  in  drops. 
Complete  retention  of  urine  is  rare,  except  in  cases 
where  a  stricture  has  previously  existed.  Pain  is  not 
limited  to  urination,  but  is  continuous  and  radiates  to 
the  groins,  testicles,  thighs,   and  back.     When  the 

WATSON. — F 


66    GONORRHCEA  &  ITS  COMPLICATIONS 

prepuce  is  long,  the  inflammation  contracts  its 
orifice,  retraction  becomes  impossible,  and  thus 
phimosis  is  produced.  This  interferes  with  the  free 
escape  of  the  discharge,  and  numerous  pyogenic 
organisms  other  than  the  gonococcus  make  their 
appearance  and  excite  inflammation  of  the  skin  of  the 
glans  and  coronal  sulcus  (balanitis  and  posthitis) 
with  erosions,  fissures,  and  sometimes  sinus  formation. 
The  impossibility  of  maintaining  cleanliness  pre- 
disposes to  the  growth  of  venereal  warts  (condylo- 
mata acuminata).  This  state  of  affairs  complicates  the 
diagnosis  and  renders  treatment  difficult. 

A  short  or  retracted  prepuce  becoming  inflamed 
and  oedematous  causes  paraphimosis,  with  conse- 
quent compression  of  the  urethra,  retention  of 
the  discharge,  and  upward  spread  of  the  disease. 
Difficulty  or  even  stoppage  of  urination  may  result, 
and  in  extreme  cases  there  may  be  sloughing  of 
the  glans. 

The  lymphatics  are  invaded  by  the  gonococcus,  and 
appear  as  red  streaks  encircling  the  penis  to  join  the 
dorsal  lymphatic  vessel,  which  is  itself  inflamed  and 
prominent. 

Occasionally  there  is  found  in  the  course  of  the 
dorsal  lymphatic  vessel  near  the  root  of  the  penis,  a 
small  area  of  circumscribed  infiltration,  which  prob- 
ably arises  from  a  minute  lymphatic  gland  in  this 
position.  This  is  called  a  "  bubonulus."  It  may 
soften  and  discharge  through  the  skin.  If  incised  it 
will  be  found  to  contain  a  mixture  of  blood  and  pus, 
from  which  gonococci  may  be  cultivated. 

The  inguinal  glands  are  enlarged  and  painful,  and  a 
suppurating  bubo  may  result.  Lymphangitis  and 
lymphadenitis  may  be  due  only  to  the  action  of  the 
gonococcus    or    its    toxines,    but    frequently    other 


URETHRITIS   IN  THE   MALE  67 

organisms  are  secondarily  concerned  in  the  in- 
flammatory process. 

Chordee  is  produced  by  involvement  in  whole  or 
part  of  the  tissues  of  the  corpus  spongiosum  in  the 
inflammatory  process.  The  meshes  become  infiltrated 
with  plastic  lymph  which  agglutinates  the  walls  of 
the  spaces  and  prevents  the  tissue  from  distending 
when  called  upon  during  erection.  The  corpora 
cavernosa  are  not  involved  in  this  way,  and  when 
they  become  engorged  with  blood  the  inelastic  but 
exquisitely  sensitive  spongy  body  and  urethra  cannot 
stretch  as  required,  and  the  shortening  of  this  side 
of  the  penis  produces  a  marked  curving  of  the  organ 
forward  and  downward.  A  patient  so  affected  will 
rise  from  bed  and  by  the  application  of  cold  water 
attempt  to  reduce  the  erection,  but  immediately  on 
returning  to  the  warm  bed,  the  state  of  matters  will 
be  as  bad  as  ever.  Maddened  with  the  torture  of  this 
condition,  violent  attempts  to  "  break  the  chordee  " 
may  be  made.  These  are  likely  to  result  in  rupture 
of  the  urethra  and  considerable  haemorrhage,  with 
traumatic  stricture  to  follow.  Fortunately,  although 
painful  erections  are  present  in  practically  all  cases, 
chordee  is  a  comparatively  rare  complication. 

The  formation  of  a  diphtheroid  membrane  on  the 
urethral  mucosa  has,  in  a  few  cases,  been  observed. 
This  condition  has  to  be  distinguished  from  the  mem- 
branous urethritis  sometimes  noticed  in  chronic  con- 
ditions when  portions  of  urethral  casts  are  shed  which 
consist  entirely  of  layers  of  epithelium.  Epithelial 
casts  are  sometimes  found  also  in  the  late  period  of  the 
acute  stage  when  strong  silver  or  other  irritating  in- 
jections have  been  used. 

Minute  firm  bodies,  varying  in  size  from  a  pinhead 
to  a  hay  seed,  may  be  felt  along  the  course  of  the 


68    GONORRHCEA  &  ITS  COMPLICATIONS 

urethra  on  the  under  surface  of  the  penis.  These  are 
inflamed  glands  and  lacunae,  and  their  presence  indi- 
cates that  the  gonococci  have  penetrated  deeply  into 
the  glands  and  is  thus  of  unfavourable  import  as  re- 
gards prognosis. 

Para-urethral  passages   are  now  known  to  be   of 
fairly  frequent  occurrence.     When  present  they  are 
likely  to  become  infected,   in  which  case  they  con- 
stitute a  tedious  complication  unless  excision  of  the 
whole  passage  or  destruction  by  electrolysis  is  feasible. 
These    offshoots    of    the    urethra    usually    terminate 
blindly    after    a    short  course  in  the   corpus  spongi- 
osum,   but    great    variety    as    regards    length    and 
course  occurs.     Thus  they  may  penetrate  into  the 
corpus  cavernosum,  and  in  rare  cases  they  may  open 
externally  either  close  to  the  lips  of  the  meatus  or 
near    the    frcenum,  forming    an    accessory    urethra. 
More  commonly,  passages  which  communicate  with 
the  exterior  have  no  connection  with  the  urethra,  but 
after  a  longer  or  shorter  course  terminate  blindly  or 
in   another   external   opening.      Such   passages   have 
been  found  on  the  under  surface  of  the  penis  running 
parallel  with  the  dorsal  lymphatic  vessel.    Two  cases 
have  been  reported  where  the  situation  was  on  the 
lateral  walls  of  the  penis.     It  is  possible  for  such 
passages  as  have  only  an  external  skin  opening  to 
become    infected    by    the    gonococcus    without    an 
accompanying  urethritis,  and  authentic  instances  of 
this  have  undoubtedly  occurred. 

When  a  para-urethral  diverticulum  emanating 
from  the  urethra  becomes  converted  into  a  cystic  or 
pseudo-abscess  it  can  be  felt  as  a  firm,  tensely  elastic 
body  varying  in  size  from  a  rice  grain  to  a  cherry- 
stone in  the  substance  of  the  penis.  They  usually 
rupture  into  the  urethra.     The  accessory  urethras 


URETHRITIS   IN   THE  MALE  69 

when  acutely  inflamed  are  seen  as  projecting  cords, 
and  the  overlying  skin  is  usually  reddened.  The 
importance  of  these  para-urethral  canals  is  very 
great,  in  that  they  tend  to  indefinitely  prolong  the 
infection. 

Cowper's  glands,  the  ducts  of  which  open  into  the 
bulbous  urethra,  may  become  implicated  during  the 
course  of  an  acute  anterior  urethritis  when  the  dis- 
ease reaches  the  mucous  membrane  of  the  bulb. 
Gonococcal  growth  may  spread  along  a  duct,  and 
should  the  walls  become  adherent  during  the  inflamma- 
tion or  the  lumen  occluded  by  the  swelling  of  its  mem- 
brane, the  result  would  be  a  retention  cyst,  the  con- 
tents of  which  would  become  purulent,  forming  a 
pseudo-abscess.  This  condition  is  evidenced  by  pain 
and  swelling  in  the  perineum  on  one  side  of  the  middle 
line  owing  to  the  appearance  of  a  tender  node  the 
size  of  a  cherry  or  larger.  The  inflammation  tends  to 
spread  forwards  towards  the  bulb,  the  direction  in 
which  the  duct  runs.  Sitting,  walking,  urination, 
and  defecation  are  accompanied  by  an  increase  in  the 
pain.     Sometimes  both  glands  are  affected. 

The  subjective  symptoms  of  inflammation  of  Cow- 
per's glands  are  similar  to  acute  inflammation  of  the 
bulb,  but  palpation  of  the  inflamed  gland  in  its 
anatomical  position  in  the  perineum  makes  the 
differential  diagnosis  a  matter  of  little  difficulty. 
The  gland  can  be  grasped  between  the  forefinger  and 
the  thumb,  the  former  being  in  the  rectum  and  the 
latter  on  the  perineum  in  front  of  the  anus.  Cow- 
peritis  is  not  in  my  experience  a  rare  complication. 
If  diagnosed  soon  after  its  onset  the  adoption  of 
antiphlogistic  measures  will  in  many  cases  cause 
subsidence  of  the  inflammation  ;  but  if  it  tends  to 
burst,  it  should  at  once  be  incised  in  the  perineum, 


70    GONORRHCEA  &  ITS  COMPLICATIONS 

otherwise  it  may  rupture  both  into  the  urethra  and 
externally,  causing  a  troublesome  fistula.  Chronic 
inflammation  of  a  Cowper's  gland  is  suggestive  of  an 
underlying  tubercular  condition.  An  acute  Cow- 
peritis  is  said  to  be  a  not  infrequent  complication  of 
pneumonia. 

The  occurrence  of  stricture  formation  during  the 
course  of  an  acute  anterior  urethritis  is  rare.  Stric- 
ture is  associated  as  a  rule  with  chronic  gonorrhoea, 
but  it  may  exist  in  acute  conditions  as  a  result  of  para- 
urethral infiltration  or  of  traumatism  of  the  urethra 
from  injudicious  treatment. 

Gonococcus  metastasis  is  quite  uncommon  during 
an  uncomplicated  urethritis  limited  to  the  anterior 
urethra,  and  is  practically  always  associated  with 
posterior  gonorrhoea. 


ACUTE   POSTERIOR   GONOCOCCAL   URETHRITIS 

It  has  already  been  stated  that  in  about  70  per  cent 
of  untreated  or  insufficiently  treated  gonorrhoeas,  in- 
fection of  the  posterior  portion  of  the  urethra  follows 
in  the  natural  course  of  events.  Finger  asserts  that 
the  extension  of  the  disease  is  to  be  expected  in  the 
third  week,  by  which  time  the  colonies  of  gonococci 
have  extended  by  continuity  of  growth  along  the  wall 
of  the  urethra  to  the  bulb  and  the  entrance  to  the 
posterior  urethra.  It  is  now  known  that  fresh  isolated 
colonies  are  started  by  deposition  of  cocci  from  the 
retained  discharge,  and  that  in  many  cases  the  bulb 
contributes  to  the  gonorrhoea  as  early  as  the  first 
week. 

As  soon  as  infection  reaches  beyond  the  pendulous 
portion  of  the  anterior  urethra,  the  discharge  will,  on 
account  of  the  slightly  downward  inclination  of  the 


URETHRITIS   IN  THE   MALE  71 

perineal  portion  of  the  canal  as  it  passes  backward 
to  the  bulb,  tend  to  gravitate  posteriorly,  thus  in- 
evitably infecting  the  whole  remaining  part  of  the 
anterior  urethra.  Erections  doubtless  precipitate 
the  backward  movement  of  infective  material,  and 
this  probably  explains  much  of  their  harmful  effect 
on  the  course  of  the  disease. 

Heissler,  observing  fifty  cases,  noted  the  onset  of 
posterior  urethritis  during  the  first  week  following 
infection  in  20  per  cent  of  his  cases,  during  the 
second  week  in  34  per  cent,  during  the  third  week  in 
14  per  cent,  and  during  the  fourth  week  in  20  per  cent 
of  cases. 

The  involvement  of  the  posterior  urethra  intro- 
duces the  serious  element  into  the  case.  The  course 
of  the  disease  is  prolonged,  in  a  considerable  propor- 
tion of  cases  indefinitely,  the  liability  to  complica- 
tions is  greatly  increased,  and  local  treatment  is 
rendered  more  difficult.  This  is  due  to  the  many 
passages  opening  into  this  division  of  the  urethra, 
some  of  which  may  act  as  lurking-places  for  the 
organism,  while  others  communicate  with  impor- 
tant structures  susceptible  to  gonococcal  inflamma- 
tion. 

That  nature  can  in  the  smaller  percentage  of  cases 
successfully  oppose  the  backward  spread  of  the  dis- 
ease is  due  to  two  obstacles  to  the  extension  of  the 
gonococcal  growth.  These  are  (a)  the  closure  of  the 
membranous  urethra  by  the  tonic  contraction  of  its 
circular  muscle  fibres,  striped  and  unstriped,  and  (b) 
the  relative  insusceptibility  of  the  mucosa  of  the 
membranous  urethra  to  the  action  of  the  gonococcus. 
The  effectiveness  of  these  deterrent  factors  varies  in 
different  individuals.  Not  uncommonly  the  epi- 
thelium on  the  lower  wall  of  the  membranous  urethra 


72    GONORRHOEA  &  ITS  COMPLICATIONS 

is  of  the  columnar  type  and  susceptible  to  gonorrhoeal 
inflammation.  The  onset  of  posterior  urethritis  may 
be  determined  either  during  the  process  of  an  acute 
or  chronic  anterior  urethritis  or  following  an  exacer- 
bation by  the  occurrence  of  erections,  by  indiscretions 
in  food  or  drink,  by  excessive  exercise,  and  by  un- 
suitable treatment.  The  subjective  symptoms  of 
posterior  urethritis  are  in  about  one-half  of  all  cases 
slight  in  character,  and  may  not  attract  special 
notice  at  the  time.  Apart  from  some  increase  in  the 
discharge  and  in  the  frequency  of  micturition,  the 
patient  may  be  unconscious  of  any  untoward  develop- 
ment. The  inflammation  reaches  its  height  in  two  or 
three  days,  and  the  most  serious  consequences  in 
these  mild  cases  is  the  prolongation  of  the  disease 
which  inevitably  ensues.  In  the  other  50  per  cent  of 
cases  the  onset  is  accompanied  by  severely  acute 
symptoms.  This  difference  in  the  reaction  of  the 
posterior  urethra  to  gonococcal  invasion  is  in  accord 
with  what  is  found  in  any  form  of  irritation  of  the 
pars  posterior.  It  has  been  proved  experimentally 
that  one  urethra  posterior  is  very  sensitive  to  irrita- 
tion, while  in  another  inflammation  is  not  easily 
excited.  In  employing  Guyon's  method  of  treating 
posterior  urethral  disease  by  instillation  of  small 
quantities  of  strong  silver  solutions  the  same  diverse 
results  are  seen,  some  cases  developing  tenderness 
and  pain,  and  others  suffering  little  discomfort.  The 
difference  in  the  acuteness  of  the  symptoms  displayed 
by  these  varieties  of  posterior  urethritis  is  therefore 
explained  by  variations  in  the  sensitiveness  of  the 
normal  mucosa. 

In  the  acute  type,  the  most  urgent  symptom  is  the 
excessive  frequency  in  micturition,  often  amounting 
to   strangury.     The   patient  is  impelled  to  urinate 


URETHRITIS   IN   THE   MALE  73 

every  hour  or  even  less.  In  the  worst  cases,  urine  is 
passed  in  small  quantities  every  few  minutes.  The 
attempt  is  accompanied  by  great  pain  and  consider- 
able straining,  and  the  emptying  of  the  bladder  is  not 
followed  by  relief  from  the  pressure.  A  characteristic 
symptom  is  the  discharge  of  a  few  drops  of  blood  at 
the  end  of  micturition.  This  is  known  as  "  terminal 
haematuria."  The  haemorrhage  does  not  come  from 
the  bladder.  This  has  been  proved  by  the  introduc- 
tion of  a  catheter.  It  is  probably  expressed  from  the 
blood-vessels  of  the  prostatic  urethra  Avhose  walls  have 
been  injuriously  affected  by  the  inflammatory  process 
and  are  unable  to  cope  with  the  sudden  and  frequent 
alterations  in  tension.  Another  possible  source  is  the 
sinus  pocularis,  in  which  case  the  haemorrhage  would 
be  analogous  to  metrorrhagia.  Sometimes  a  worm- 
like clot  is  expelled  with  the  first  portion  of  urine. 

The  discharge  may  not  be  obviously  increased  as 
it  is  washed  away  by  the  frequent  acts  of  urination, 
but  if  the  urine  is  collected  and  examined  it  will  be 
seen  to  contain  a  considerable  quantity  of  pus. 
Another  reason  for  there  being  no  apparent  increase 
in  the  discharge  is  that  during  any  considerable  in- 
terval of  urinary  retention  the  discharge  finds  its 
way  backward  into  the  bladder  rather  than  forward 
into  the  anterior  urethra,  from  which  it  is  shut  off 
by  the  external  sphincter. 

Erections  are  not  so  markedly  a  symptom  of 
posterior  urethritis  as  of  anterior,  but  painful  and 
bloodstained  emissions  are  occasionally  a  source 
of  distress  to  the  patient.  The  temperature  rises, 
especially  at  night,  to  from  100°  to  104°  F.  Pain 
in  the  perineum,  thighs,  and  back  is  a  cause  of  much 
complaint.  The  night's  rest  is  greatly  disturbed, 
and  the  patient's  condition  is  one  of  severe  illness. 


74    GONORRHCEA  &  ITS  COMPLICATIONS 

Albuminuria  in  excess  of  what  can  be  accounted  for 
by  the  presence  of  pus  in  the  urine  is  present  in 
10  per  cent  to  15  per  cent  of  cases  of  acute  posterior 
urethritis. 

In  only  a  very  small  proportion  of  cases  is  this 
albuminuria  associated  with  extension  of  the  disease 
to  the  kidney.  It  is  always  accompanied  by  urinary 
tenesmus,  and  ceases  when  the  urinary  pressure  is 
relieved,  e.g.,  by  atropine.  It  may  therefore  be 
accounted  for  by  the  occurrence  of  a  reversed  peristal- 
tic action  passing  up  the  ureter  to  the  pelvis  of  the 
kidney  and  interfering  with  its  function. 

The  diagnosis  of  posterior  urethritis  is  rendered 
certain  by  an  examination  of  the  urine  in  separate 
portions.  Sir  Henry  Thompson's  original  method 
(1868)  was  to  use  two  glasses  as  receptacles  for  the 
first  and  second  halves  of  the  urine.  The  first  urine 
washes  out  the  whole  urethra,  and  will  contain  such 
pus  as  may  have  been  lying  in  the  canal  or  adhering 
to  its  walls.  The  second  glass  contains  the  contents 
of  the  bladder  unmixed  with  discharge  from  the  an- 
terior urethra.  As  the  discharge  of  posterior  ure- 
thritis regurgitates  into  the  bladder,  pus  in  the  second 
portion  of  the  urine  in  the  Thompson  test  indicates 
the  presence  of  a  posterior  urethritis.  In  very  severe 
cases,  frequently  passing  driblets  of  urine,  a  quantity 
sufficient  for  this  test  may  not  be  obtainable,  but  in 
such  cases  there  is  already  little  doubt  about  the 
diagnosis.  A  rectal  examination  will  show  the  pre- 
sence of  tenderness  of  the  prostatic  portion  and  decide 
the  question.  In  less  acute  cases  it  is  advisable  to 
divide  the  urine  into  three  volumes.  The  first  glass 
should  contain  not  more  than  two-thirds  of  the  total 
quantity,  the  second  one-third,  and  the  third  glass 
the  last  drops  of  the  urine.     Before  using  the  third 


URETHRITIS    IN   THE   MALE  75 

glass  for  the  final  drops  of  urine  the  prostate  may  be 
gently  massaged  if  thought  advisable.  In  antero- 
posterior urethritis,  the  first  glass  will  show  pus  from 
the  bladder  and  the  entire  urethra.  The  second  will 
still  show  pus,  but  in  less  quantity,  as  it  contains  the 
contents  of  the  bladder  only.  The  third  may  show 
greater  concentration,  as  it  may  contain  pus  which 
has  gravitated  into  a  pocket  of  the  bladder  at  a  level 
below  the  vesical  opening  of  the  urethra,  and  in 
addition  such  pus  as  may  be  expressed  during  the 
last  straining  efforts  of  urination  from  the  ducts  in 
the  prostatic  urethra. 

When  the  discharge  is  scanty,  greater  accuracy  can 
be  obtained  by  a  preliminary  washing  out  of  the 
anterior  urethra  to  remove  whatever  pus  it  contains. 
This  is  best  carried  out  by  means  of  a  large  glass 
syringe,  with  which  the  anterior  urethra  is  carefully 
injected  several  times,  until,  in  fact,  the  washings 
return  quite  clear.  The  pus-contaminated  water  is 
collected  in  glass  one,  glass  two  is  used  as  a  control 
glass  to  contain  several  further  clear  washings.  Into 
glasses  three,  four,  and  five  the  patient  now  passes 
urine  as  in  the  three-glass  test.  If  pus  is  present  in 
the  urine  it  must  be  derived  from  the  posterior  ure- 
thra, and  indicates  an  active  posterior  urethritis. 
This  test  should  preferably  be  performed  in  the 
morning  before  the  patient  has  passed  urine,  and  in 
any  case  a  three-hours'  interval  is  necessary  to  allow 
a  sufficient  quantity  both  of  urine  and  discharge  to 
collect.  The  patient  should  stand  while  the  urethra 
is  being  washed  out  by  the  surgeon,  and  sterile  water 
or  a  mildly  antiseptic  solution,  e.g.,  boric  acid,  should 
be  used.  An  irrigating  apparatus  fitted  with  a  small 
conical  glass  nozzle  instead  of  a  syringe  may  be  used. 
The   reservoir   should   contain   a   pint   of   fluid.      It 


76    GONORRHCEA  &  ITS  COMPLICATIONS 

must  not  be  raised  beyond  a  height  of  two  and  a  half 
feet  above  the  level  of  the  urethra,  otherwise  the 
irrigating  solution  might  penetrate  into  the  posterior 
urethra.  The  urethral  nozzle  is  inserted  at  the  lower 
angle  of  the  meatus,  while  the  upper  angle  is  con- 
trolled by  the  thumb  and  forefinger  of  the  operator. 
Closing  of  the  ujDper  part  of  the  meatus  enables  the 
anterior  urethra  to  be  distended  with  the  solution, 
and  then  relaxing  the  fingers  enables  the  fluid  to 
escape  into  a  glass  receiver  without  removing  the 
nozzle.  If  the  shape  of  the  meatus  does  not  lend  itself 
to  this  procedure,  the  urethra  is  alternately  filled  and 
emptied  by  closure  of  the  meatus  with  the  canula 
and  its  withdrawal  as  soon  as  the  urethra  is  gently 
distended.  This  lavage  of  the  canal  is  continued  until 
the  washings  return  absolutely  clear,  showing  that 
the  anterior  urethra  is  completely  free  from  pus. 

In  washing  out  the  anterior  urethra  the  canal  may 
be  compressed  at  any  selected  point  and  cleansed  in 
sections  if  it  is  thought  desirable  to  investigate  the 
condition  of  the  separate  areas. 

It  need  hardly  be  mentioned  that  the  possibility 
of  the  cloudiness  of  the  urine  not  being  due  to  pus 
must  be  eliminated.  The  possible  sources  of  error  are 
phosphates,  urates,  mucus,  and  bacteria.  Urates 
will  dissolve  on  heating ;  phosphates  on  addition  of 
acetic  acid  ;  bacteriuria  must  be  diagnosed  by  the 
microscope  ;  and  the  addition  of  a  solution  of  caustic 
potash  or  soda  will  convert  pus  into  a  ropy  gelatinous 
mass. 

The  complications  and  sequelae  liable  to  follow  in 
the  train  of  a  posterior  urethritis  will  be  indicated 
by  a  reference  to  the  anatomy  of  the  posterior 
urethra.  Extension  of  the  inflammation  along  the 
ducts  of  the  prostate  gland  produces  the   different 


URETHRITIS    IN   THE   MALE  77 

types  of  prostatitis.  The  sinus  pocularis  is  fre- 
quently attacked,  and  it  may  be  a  source  of  long- 
continued  trouble.  Reversed  peristaltic  action  carries 
the  infection  along  the  ejaculatory  ducts  to  the 
vesiculae  seminales  which  are  susceptible  to  gonococ- 
cal inflammation,  and  also  along  the  vas  deferens  to 
the  epididymis,  producing  epididymitis.  These  com- 
plications are  so  important  as  to  require  detailed  con- 
sideration in  following  chapters. 


CHAPTER   V 

TREATMENT  OF   ACUTE  GONOCOCCAL  URETHRITIS 

The  objective  of  all  treatment  is  the  eradication  of 
the  gonococcus  and  the  repair  of  the  damaged  tissues. 
A  direct  attack  on  the  organism  is  rendered  difficult, 
owing,  in  the  first  place,  to  the  sensitiveness  of  the 
urethral  mucous  membrane,  especially  when  it  is  in 
an  inflamed  condition ;  and  secondly,  on  account  of  the 
early  penetration  of  the  gonococcus  into  the  inter- 
stices of  the  epithelial  and  subepithelial  layers.  The 
therapeutic  agent  adopted  should  therefore  be  one 
which,  in  addition  to  being  lethal  to  the  gonococcus, 
possesses  a  maximum  of  penetrating  power  and  a 
minimum  of  irritating  property. 

The  progress  of  the  disease  can  be  influenced  by 
efforts  to  stimulate  the  patient's  immunising  mechan- 
ism, and  also  by  attempts  to  render  the  tissues  of  the 
host  unsuitable  as  a  medium  for  the  growth  of  the 
gonococcus.  To  be  able  to  cure  gonorrhoea  either  by 
establishing  an  immunity,  general  or  local,  or  by 
the  employment  of  an  antiseptic  effective  against  the 
gonococcus  while  harmless  to  the  tissues,  is  still, 
however,  an  ideal  very  incompletely  realised  in 
practice.  Meantime,  by  the  adoption  of  a  judicious 
compromise,  it  is  possible  to  assert  a  control  of  the 
disease  in  so  far  that  it  can  be  localised  in  the  anterior 
urethra,  complications  can  be  averted,  and  cure  can 
be  hastened. 

Prophylaxis    of    gonorrhoea,    a    question    of    some 

78 


ACUTE    GONOCOCCAL    URETHRITIS     79 

delicacy,  but  of  much  practical  importance,  is  con- 
sidered in  the  final  chapter. 

The  general  treatment  aims  at  the  removal  of  all 
influences  favourable  to  the  extension  of  the  inflam- 
matory process,  and  includes  hygienic,  dietetic,  and 
antiphlogistic  measures.  Confinement  to  bed  is  only 
necessary  in  hyperacute  cases  or  on  the  appearance  of 
complications,  but  fatigue  must  be  carefully  guarded 
against,  and  during  the  acute  stage  all  forms  of 
exercise  should  be  prohibited.  Horse  riding  and 
cycling  are  particularly  harmful,  and  even  walking 
should  be  avoided  as  much  as  possible.-  The  patient 
should  drive  rather  than  walk,  sit  rather  than  stand, 
and  recline  rather  than  sit.  Scrupulous  cleanliness 
should  be  maintained.  The  glans,  prepuce,  penis, 
and  scrotum  should  be  bathed  two  or  three  times 
each  day  with  soap  and  water,  and  this  may  usefully 
be  followed  by  an  unirritating  antiseptic  lotion.  The 
hands  should  be  washed  after  each  contact  with  the 
affected  parts.  Hot  sitz  baths,  105°  to  110°  F.,  before 
retiring  to  bed  help  to  induce  sleep  and  prevent 
erections.  When  micturition  is  excessively  painful, 
immersion  in  hot  water  is  often  beneficial. 

The  patient  should  be  warned  of  the  contagious 
nature  of  the  discharge.  Attention  should  be  drawn 
to  the  danger  to  his  own  eyes  from  unclean  hands, 
towels,  or  water,  as  well  as  the  risk  of  infecting  others 
who  may  use  the  same  toilet  articles.  A  gauze  or 
lint  bag  in  which  the  penis  is  freely  movable  should 
be  worn  to  protect  the  clothing.  The  practice  of 
leaving  a  piece  of  dry  wool  adhering  to  the  meatus 
and  damming  back  the  discharge  cannot  be  too 
forcibly  condemned.  The  only  occasion  on  which 
this  practice  should  be  resorted  to  is  when  taking  a 
bath. 


80    GONORRHOEA  &  ITS  COMPLICATIONS 

Chills  should  be  guarded  against,  and  the  feet 
especially  should  be  protected  from  damp  and  cold. 
Sleep  should  be  secured  by  hypnotics  if  necessary,  and 
a  hard,  cool  bed  in  a  well-ventilated  room  should  be 
chosen.  Every  effort  should  be  made  to  maintain 
rest  of  the  affected  region.  Suspensory  bandages 
are  sometimes  useful,  but  care  must  be  taken  to  see 
that  at  no  point  is  there  any  compression  of  the  penis 
interfering  with  free  drainage  or  blood  supply.  Sus- 
pensories as  commonly  used  are  more  often  harmful 
than  helpful.  It  is  of  the  utmost  importance  to  avert 
all  excitation  of  the  sexual  organs  and  to  encourage  a 
condition  of  mind  which  will  keep  the  sexual  function 
not  only  in  a  state  of  rest,  but  in  abeyance.  The 
inflammatory  hypersemia  tends  to  induce  involuntary 
erections  and  emissions,  which  exercise  a  serious 
influence  on  the  course  of  the  disease  and  are  respon- 
sible, more  than  any  other  factor,  for  extensions  and 
complications.  This  tendency  may  therefore  have  to 
be  combated  by  anaphrodisiacs  and  sedatives  such  as 
camphor,  potassium  bromide,  lupuline,  adamon,  anti- 
pyrine,  veronal,  trional,  atropine,  heroin,  or  morphia. 
Finger  gives  the  following  prescription  : — 

^     Lupuline     .  .  .  .1-0 

Camphor     ....      1-1 
Ext.  Lupuli  .  .  .     q.  s. 

ft.  pil  X. 

Sig.  six  pills  daily. 

Camphor  monobromate  in  doses  of  five  to  eight 
grains  in  cachets  may  be  taken  once  or  twice  before 
bedtime.  To  ensure  sleep  and  freedom  from  erections, 
it  is  sometimes  necessary  to  prescribe  morphine  in 
suppository  form  or  as  a  hypodermic  injection. 
When  an  erection  occurs,  it  should  be  dealt  with  by  the 


ACUTE   GONOCOCCAL    URETHRITIS     81 

application  of  cold  water  followed  by  the  emptying 
of  the  bladder.  Sometimes  the  immersion  of  the 
hands  in  cold  water  suffices  to  give  relief,  or  a  large 
warm  rectal  enema  may  prove  efficacious. 

The  diet  during  the  height  of  the  inflammatory 
symptoms  should  be  restricted  to  milk,  carbohydrates, 
vegetables,  and  non-acid  fruits.  Asparagus,  celery, 
tomatoes,  shell-fish,  lobster,  ginger  ale,  pickles,  sauces, 
spices,  and  condiments  should  be  avoided.  A  safe 
rule  is  to  prohibit  any  article  of  diet  which  "  tickles  " 
the  palate.  As  the  symptoms  decrease  in  severity  the 
dietary  can  be  enlarged,  fish,  chicken,  and  red  meat 
being  allowed  in  moderation.  The  patient  should  be 
encouraged  to  drink  freely  to  ensure  a  copious  flow  of 
dilute  urine.  Coffee  is  unsuitable  in  many  cases,  but 
weak  tea  with  plenty  of  milk  may  be  allowed.  Barley 
water  is  an  excellent  drink,  and  Evian  or  any  similar 
faintly  alkaline  mineral  water  may  be  prescribed  for 
those  who  are  not  contented  with  plain  water. 
Alcohol  is,  of  course,  entirely  forbidden.  The  reason 
why  all  alcoholic  beverages  react  so  banefully  on 
gonorrhoea  is  not  easily  explained,  but  there  is 
abundant  clinical  experience  to  justify  their  entire 
prohibition  during  the  whole  course  of  the  infection. 
Some  continental  authorities  recommend  a  reduced 
allowance  of  light  wine  to  patients  who  have  been 
habituated  to  its  use,  but  the  safe  course  is  total 
abstinence. 

Regular  evacuation  of  the  bowels  should  be  ob- 
tained by  using,  when  necessary,  a  mild  laxative  such 
as  cascara.  Aloes  and  aloin  should  be  avoided  ;  and 
any  drug  such  as  citrate  of  lithia  or  carbonate  of  mag- 
nesium, which  in  some  patients  is  prone  to  produce 
phosphaturia,  should  not  be  prescribed,  as  the  passage 
of  phosphatic  deposit  is  exceedingly  painful. 

WATSON.  —  G 


82    GONORRHCEA  &  ITS  COMPLICATIONS 

The  internal  treatment  of  gonorrhoea  is  still  the 
favourite  and  sole  method  of  treatment  adopted  by 
the  inexpert  for  three  reasons :  {a)  its  comparative 
harmlessness;  (h)  the  small  amount  of  trouble  involved; 
and  (c)  the  good  results  apparently  obtained  in  many 
cases.  Close  clinical  study  of  the  after  effects  of  the 
disease,  as  well  as  bacteriological  control  of  the 
progress  of  cases,  have,  however,  abundantly  proved 
the  insufficiency  of  the  method  and  the  folly  of 
relying  on  drugs  to  effect  a  cure.  There  are  several 
medicines,  more  especially  some  balsamics  and  aro- 
matic oils,  which  have  a  beneficial  effect  on  the  more 
conspicuous  symptoms  of  gonorrhoeal  urethritis,  and 
there  is  no  reason  why  they  should  not  be  used  for 
the  purpose  for  which  they  are  suited,  so  long  as  they 
are  recognised  both  by  the  doctor  and  patient  as  being 
subsidiary  to  the  local  treatment  by  which  alone  can 
the  infection  be  controlled  and  the  gonococcus 
exterminated. 

The  internal  remedies  which  are  in  general  use  are 
copaiba,  cubebs,  sandal-wood  oil,  kava-kava,  buchu, 
methylene  blue,  and  the  urinary  antiseptics.  The 
action  of  the  balsamics  is  due  to  a  local  effect  of  their 
disintegration  products  on  the  mucous  membrane  of 
the  urethra.  These  products  are  for  the  most  part 
excreted  by  the  kidneys,  and  they  are  therefore 
brought  into  contact  with  the  urethral  mucosa 
mainly  during  micturition.  It  is  probable  that  the 
urethral  glands  play  some  small  part  in  the  elimina- 
tion. The  balsamics  have  little  appreciable  antiseptic 
action.  That  they  do  not  inhibit  directly  the  growth 
of  the  gonococcus  is  proved  by  the  fact  that  the  gono- 
coccus flourishes  on  media  to  which  the  urine  of 
patients  previously  dosed  with  balsamics  has  been 
added.     Their  therapeutic  action  is  threefold  :    (a) 


ACUTE   GONOCOCCAL    URETHRITIS     83 

they  relieve  pain  (an  anaesthetic  effect  has  been 
demonstrated  on  the  eye  of  the  rabbit);  (b)  they 
decrease  the  discharge  and  astringe  the  urethral 
mucosa;  (c)  they  act  as  anaphrodisiacs  (this  effect 
is,  however,  uncertain  and  slight). 

Their  first  effect  is  to  stimulate  engorged  and  torpid 
cells  into  activity,  and  their  preliminary  action  is 
therefore  to  increase  the  discharge.  On  this  account 
it  is  usually  advised  that  they  should  be  withheld 
during  the  few  days  in  which  the  inflammation  is  at 
its  height. 

Copaiba,  so  far  as  European  practice  is  concerned, 
has  been  longest  in  use.  It  is  a  fluid  oleo-resin, 
obtained  from  the  trunk  of  certain  species  of  Copaif era. 
It  has  a  yellowish  colour,  characteristic  aromatic 
odour,  and  acrid,  somewhat  nauseous  bitter  taste.  A 
large  dose  or  persistent  use  is  apt  to  produce  dyspep- 
sia, sickness,  and  diarrhoea.  The  dose  is  J  to  1  fluid 
dram  in  capsules  or  emulsion.  A  tell-tale  odour  is 
emitted  by  patients  undergoing  treatment  with  this 
drug,  and  occasionally  it  produces  erythema  or 
roseola,  or  an  urticaria  due  to  indigestion.  Ricord 
made  free  use  of  copaiba,  and  reports  a  case  in  which 
the  presence  of  a  fistula  enabled  him  to  demonstrate 
the  value  of  the  treatment  in  allaying  the  inflamma- 
tory appearances.  The  fistula  communicated  with 
the  urethra  and  opened  externally  in  front  of  the 
scrotum.  In  micturition  the  urine  escaped  through 
the  fistula,  but  on  closing  the  fistula  by  digital 
pressure  the  urine  passed  naturally  from  the  meatus. 
Ricord  prescribed  copaiba  and  instructed  the  patient 
to  urinate  through  the  fistula.  In  a  few  days  the 
"  running "  from  this  part  was  cured,  while  the 
anterior  segment  remained  unimproved.  By  passing 
urine    through    the    whole    canal,    cessation    of    the 


84     GONORRHCEA  &  ITS  COMPLICATIONS 

discharge  was  soon  secured.  Ricord  noted  that 
copaiba  seemed  to  undergo  some  change  in  the 
process  of  absorption  which  was  essential  to  the 
development  of  its  curative  properties,  for  injections 
of  an  emulsion  proved  comparatively  useless,  while 
the  urine  of  patients  ingesting  the  drug  was  efficacious 
as  an  injection.  The  active  principles  of  copaiba  and 
cubebs  are  present  in  the  urine  as  acids  in  combination 
with  potassium  or  sodium,  and  the  addition  of  a 
strong  acid — for  example,  nitric  acid — precipitates  a 
white  flocculent  deposit,  which  is  distinguishable 
from  albumen  by  the  fact  that  it  is  soluble  in  alcohol. 
Some  patients  are  intolerant  of  copaiba,  and  its 
action  not  only  on  the  digestive  system,  but  on  the 
urinary  organs,  must  be  carefully  watched.  On  the 
appearance  of  albumen  or  blood  in  the  urine  the  drug 
must  be  withdrawn. 

Cubebs  is  the  dried  unripe  fruit  of  Piper  cubeba. 
The  dose  is  30-60  grains  of  the  powder  and  30-60 
minims  of  the  oil.  Cubebs  is  less  unpleasant  to  the 
palate  than  copaiba  and  less  liable  to  upset  the 
digestion.  It  is  frequently  prescribed  along  with 
copaiba  either  in  pill,  paste,  or  emulsion  form.  The 
powder  may  be  administered  in  milk. 

Oleum  Santali  is  a  pale  yellow  oil  distilled  from  the 
wood  of  East  Indian  Santalum  album.  The  dose  is 
5-30  minims  in  capsule  or  emulsion.  The  taste  is 
aromatic  and  somewhat  pungent,  but  it  is  much  less 
irritating  to  the  digestive  system  and  to  the  kidneys 
than  copaiba  and  cubebs,  and  has  therefore  almost 
entirely  displaced  them  in  therapeutics.  \ATien  ill 
effects  follow  the  use  of  sandal-wood  oil  they  may  be 
due  to  impurities  such  as  cedar-wood  oil  or  West 
Indian  sandal  oil.  The  active  principle  is  santalol,  a 
sesquiterpen-alcohol.     Occasionally   a   precipitate  is 


ACUTE   GONOCOCCAL    URETHRITIS     85 

seen  on  the  addition  of  nitric  acid  to  the  urine  as 
occurs  with  cubebs  and  copaiba.  Sandal-wood  oil 
appears  to  have  a  specific  antiseptic  action  on 
staphylococci  in  the  urine,  and  this  may  apply  to 
cocci  generally  (Jordan). 

Kava-kava  is  the  dried  rhizome  of  Piper  methysti- 
cu?n  (Polynesia).  The  preparation  used  is  the  liquid 
extract  in  doses  of  30-60  minims.  It  is  not  unpleasant 
in  taste  or  after  affects,  and  is  similar  in  action  to  the 
other  balsamics,  but  has  a  particularly  strong  anaes- 
thetic effect. 

The  salicylates  are  frequently  of  service. 
Methylene  blue  is  now  seldom  employed. 
The    urinary    antiseptics^  such    as    hexamethylen- 
tetramine,  salol,  and  boric  acid,  have  no  specific  action, 
but  their  occasional  use  is  of  advantage,  especially 
when  instruments  are  being  passed  into  the  bladder. 
They  must  be  used  intelligibly,  otherwise  they  will 
prove  disappointing.    The  only  drugs  which  need  be 
considered   are    hexamethylen-tetramine,   commonly 
known  by  the  trade-name  urotropine,  and  boric  acid. 
The  antiseptic  action  of  urotropine   depends  on  its 
power  of  forming  formaldehyde  in  the  urine  ;  but  this 
is  only  produced  in  an  acid  urine,  and  the  higher  the 
degree  of  acidity  the  more  effective  is  urotropine  as  an 
antiseptic.     The  urine  must  therefore  be  tested  in 
every  case,  and  if  found  to  be  neutral  or  alkaline  it 
may  be  possible  to  alter  the  reaction  by  administering 
the  acid  phosphate  of  sodium  30  or   60    grains,  or 
sodium  benzoate  15-20  grains,  twice  daily.      Urotro- 
pine on  a  rare  occasion  may  give  rise  to  symptoms  of 
intolerance,  producing  even  hsematuria  and  strangury. 
Now  it  must  be  admitted  that  a  highly  acid  urine 
containing  such  an  irritating  constituent  as  formal- 
dehyde is  the  opposite  of  the  condition  we  desire  to 


86    GONORRHCEA  &  ITS  COMPLICATIONS 

produce  in  acute  urethritis,  and  therefore  urotropine 
is  not  a  suitable  antiseptic  for  acute  gonorrhoea.  It  is, 
however,  of  great  value  in  the  chronic  stage  with  a 
mixed  infection  extending  to  the  bladder. 

Boric  acid  acts  equally  well  in  an  alkaline  urine,  is 
an  efficient  antiseptic,  and  gives  rise  to  no  irritation 
of  the  urinary  tract.  It  is  therefore  the  antiseptic  of 
choice  in  acute  gonorrhoea. 

Uvce  JJrsi  is  a  mild  diuretic  with  a  weak  but 
distinct  antiseptic  action.  The  infusion  is  a  suitable 
vehicle  for  exhibiting  boric  acid,  e.g. — 

^       Ac.  Borici  or  Urotropine        .     gr.  X. 

Inf.  Uvse  Ursi       .  .  .1  oz. 

Sig.    To  be  taken  three  or  four  times  daily. 

The  balsamics  should  be  taken  immediately  after 
meals,  with  a  view  to  decreasing  their  irritating 
action  on  the  intestinal  tract.  It  has  been  recom- 
mended that  in  order  to  obtain  the  greatest  con- 
centration of  the  remedial  products  in  the  urine,  the 
quantity  of  fluid  allowed  should  be  limited,  but  the 
disadvantages  of  this  course  outweigh  any  possible 
gain.  It  must  not  be  forgotten  that  however  advan- 
tageous the  balsamics  may  be  in  reducing  the  discharge 
to  a  minimal  quantity  and  in  relieving  pain,  this 
internal  treatment  alone  will  not  effect  a  cure. 
Bacteriological  examination  will  still  reveal  the  con- 
tinued presence  of  the  gonococcus,  and  so  long  as  the 
infection  lasts  there  are  the  dangers  of  relapse,  of 
complications,  and  of  conveying  the  infection  to 
others.  Internal  medication  is  not  therefore  in 
itself  a  method  of  treatment,  but  only  an  unessential 
auxiliary  of  more  or  less  assistance  to  the  local 
treatment.  During  the  administration  of  the  bal- 
samics the  precaution  of  periodical  examination  of 


ACUTE   GONOCOCCAL    URETHRITIS     87 

the  urine  should  not  be  omitted,  and  on  any  appearance 
of  nephritic  irritation  the  medicine  should  be  altered 
to  a  simple  diuretic.  Before  collecting  a  sample  of 
urine  for  examination,  the  patient  should  pass  a 
portion  of  his  urine  sufficient  to  wash  all  pus  from 
the  urethra. 

LOCAL  TREATMENT   OF   ACUTE   GONOCOCCAL 
URETHRITIS 

Since  the  discovery  of  the  gonococcus,  the  line  of 
treatment  most  persistently  followed  has  been  local 
application  of  antiseptics  in  the  hope  of  destroying 
the  organism.    In  selecting  an  antiseptic  there  are  three 
indications  that  influence  the  choice  :    {a)  it  should 
be  active  against  the  gonococcus  in  the  urethra  ;    (6) 
it  should  be  unirritating  even  to  the  inflamed  mucous 
membrane  ;   (c)  it  should,  if  this  be  obtainable,  be  one 
which  is  capable  of  penetrating  the  living  tissues  and 
acting  on  the  gonococci  lying  in  the  subepithelial 
layer.     It  should  also  be  able  to  reach  the  depths  of 
the  glands  and  lacunae  in  which  gonococci  are  em- 
bedded.   That  there  is  no  antiseptic  or  combination  of 
antiseptics  at  present  at  our  disposal  which  entirely 
fulfils  these  demands  is  true,  and  there  is,  therefore, 
still  much  room  for  improvement  in  the  treatment  of 
gonorrhoea.    But  sufficient  progress  has  been  made  to 
establish  local  treatment  in  a  position  of  considerable 
effectiveness,  and  to  remove  any  justification  there 
might  at  one  time  have  existed  for  the  policy  of  non- 
interference   which    found    some    advocates.       The 
difficulty    has    been    to    obtain    an    antiseptic    with 
penetrative  power  and  non-irritating  to  the  living 
tissue.    No  difficulty  is  now  experienced  in  destroying 
all  surface  organisms  without  producing  undue  irrita- 
tion, and  clinical  experience  has  taught  that  if  this 


88    GONORRHCEA  &  ITS  COMPLICATIONS 

condition  be  maintained  for  a  sufficiently  long  period 
the    natural    resistance    of    the    patient,    reinforced 
possibly  by  the  use  of  vaccines,  will  be  sufficient  to 
deal    with    the    tissue-embedded    organisms.      The 
results  which  can  be  relied  on  to  follow  the  proper 
application  of  the  best  local  treatment  are  :    {a)  the 
limitation   of  the  infection  ;     (b)  the  prevention  of 
complications;    and    (c)    the    assurance  of    ultimate 
removal  of  infectivity.     The  mode  of  applying  the 
antiseptic  to  the  urethra  has    given  rise   to    much 
discussion.     There  are  two  main  schools  typified  by 
the  French  and  the  German,  who  uphold  different 
methods.    Janet,  of  Paris,  elaborated  and  popularised 
the  lavage  treatment,  by  which  a  large  volume  of  weak 
solution,  usually  of  potassium  permanganate,  is  made 
to  flow  over  the  urethral  mucous  membrane  into  the 
bladder,  whence  it  is  expelled  by  the  patient.     The 
other  method  is  the  injection  of  small  quantities  of 
stronger  solutions,  usually  of  silver  preparations,  by 
means  of  a  hand  syringe.    Among  other  methods  less 
generally  used  are  irrigation  of  the  anterior  urethra, 
the  insertion  of  solid  bougies  or  semi-solid  pastes  in 
which  antiseptics  are  incorporated,  and  the  applica- 
tion of  heat  of  a  degree  sufficient  to  destroy  the 
gonococcus.      The    small    syringe    has,    in    general 
practice,   a  greater  vogue  than  any  other  mode  of 
treatment.     Its  reputed  advantages  are  :    (a)  that  it 
can    be    carried    out    by    the    patient ;    (b)  stronger 
solutions  of  the  antiseptic  can  be  employed  ;    (c)  it 
can  be  applied  more  frequently;  and  (d)  it  does  not 
traverse  the  posterior  urethra.    When  these  assertions 
are  critically  examined,  it  can  be  said  :    (a)  treatment 
would  be  attended  with  less  risk  and  would  be  more 
effective  if  practised  only  by  the  surgeon  or  a  skilled 
attendant ;     {b   and   c)    more   thorough   removal   of 


ACUTE   GONOCOCCAL   URETHRITIS     89 

micro-organisms  can  be  secured  by  the  mechanical 
action  of  a  large  volume  of  solution  used  once  or  at 
most  twice  daily  with  less  irritating,  but  equally 
sterilising  effect  on  the  urethra  than  by  frequent 
injections  of  small  quantities  of  stronger  antiseptics  ; 
(d)  this  objection  is  more  theoretical  than  real,  and 
is  charged  with  equal  force  by  the  advocates  of  the 
Janet  system  against  the  injection  method.  Many 
able  clinicians  have,  however,  after  a  prolonged  test  of 
the  Janet  treatment,  reverted  to  the  silver  injections, 
and  the  main  reason  expressed  when  any  is  given  is 
that  complications  (prostatitis,  epididymitis,  etc.) 
are  less  frequent  with  the  latter  form  of  treatment. 
Statistics  are  not  forthcoming  on  their  side,  and  the 
followers  of  Janet  still  successfully  defend  their 
position.  My  own  preference  is  strongly  in  favour  of 
the  lavage  treatment,  circumstances  allowing  of  its 
use.  Unfortunately  the  time  and  trouble  involved 
will,  it  is  feared,  prevent  its  becoming  popular  in 
general  practice,  especially  when  good  results  can 
be  obtained  by  the  careful  employment  of  other 
means. 

We  will  consider  the  different  forms  of  treatment  as 
applied  to  acute  anterior  urethritis  in  the  following 
order  : — 

1.  Injection  treatment. 

2.  Urethro-vesical  washings  (Grand  Lavage  of  Janet). 

3.  Irrigation. 

4.  Thermic  treatment. 

5.  Bougies,  semi-solid  pastes,  ointments. 

6.  Bier  treatment. 

7.  Lactic  acid  bacilli  ;   bacillus  pyocyaneus. 

8.  Vaccines  and  serums. 

The  urethral  injection  treatment. — A  syringe  is 
chosen  which  is   capable  of  holding  an  amount  of 


90    GONORRHOEA  &  ITS  COMPLICATIONS 

fluid  sufficient  to  distend  the  anterior  urethra,  but 
small  enough  to  obviate  the  risk  of  an  excess  of 
pressure  being  employed  by  which  the  resistance  of 
the  compressor  urethrse  muscle  might  be  overcome 
and  the  fluid  forced  into  the  posterior  urethra.  The 
average  capacity  of  the  anterior  urethra  in  health  is 
from  8-12  c.c,  but  this  is  decreased  in  inflamed 
conditions,  and  a  syringe  with  a  capacity  of  two  or 
three  drams  is  therefore  suitable.  The  asepsis  of  the 
syringe  is  of  the  utmost  importance.  An  all-glass 
syringe  with  solid  plunger  and  acorn  nozzle  is  now  on 
the  market,  and  is  the  only  form  which  should  be 
employed  (Fig.  24).  The  insertion  into  the  inflamed 
canal  of  the  old-fashioned  tapering  or  olive-shaped 


Fig.  24. 
All  glass  urethral  syringe. 

nozzle  was  a  constant  source  of  irritation  and  pain. 
The  acorn  point  fits  into  the  meatus,  and  it  can  be 
kept  in  position  as  long  as  retention  of  the  injection 
is  desired.  To  attempt  to  hold  the  solution  in  the 
urethra  by  digital  compression  after  withdrawal  of 
the  syringe  means  always  some  loss  of  the  fluid,  and 
the  extremity  of  the  urethra  escapes  treatment.  The 
object  aimed  at  by  the  small  syringe  technique  is  to 
bring  the  antiseptic  solution  into  contact  with  the 
whole  surface  of  the  mucous  membrane  of  the  anterior 
urethra,  and  to  maintain  the  contact  for  several 
minutes. 

The  glans,  prepuce,  and  meatus  are  thoroughly 
cleaned  and  the  bladder  is  emptied  before  the  injec- 
tion is  begun.    It  is  advisable  to  ensure  that  all  urine 


ACUTE   GONOCOCCAL   URETHRITIS     91 

has  been  expelled  from  the  urethra  by  moving  the 
fingers  along  the  canal  from  the  bulb  forwards,  as 
the  presence  of  urine  vitiates  to  some  extent  the 
activity  of  the  antiseptics.  Cleansing  of  the  canal  by 
injections  of  warm  water  previous  to  throwing  in  the 
medicament  has  been  suggested,  but  there  is  the 
obvious  risk  by  this  procedure  of  carrying  gonococci 
into  the  posterior  urethra,  gonococci  which  have  not 
been  in  contact  with  the  antiseptic  and  whose  viru- 
lence therefore  is  unaffected. 


Fig.  25. 
MacMunn's  urethral  clamp. 

The  solution,  which  should  be  about  blood  heat,  is 
injected  evenly  and  slowly  until  the  urethra  is  com- 
pletely distended,  and  the  syringe  is  kept  in  position 
to  prevent  the  escape  of  the  injection  for  such  time  as 
has  been  decided  upon.  This  depends  on  the  strength 
of  the  solution  employed  and  the  .iruteness  of  the 
inflammation  present.  In  no  case  should  it  exceed 
ten  minutes,  as  the  compressor  muscle  might  become 
exhausted,  and  relaxation  would  allow  entrance  into 


92    GONORRHCEA  k  ITS  COMPLICATIONS 

the  posterior  urethra.     In  attempting  to   abort  an 
infection,  it  may  be  thought  advisable  to  retain  the 
antiseptic    in    the    urethra    for    twenty    minutes,    in 
which  case  at  least  two  syringefuls  should  be  used 
with  an  interval  of  a  few  minutes  between.    There  is 
some  advantage  to  be  gained  by  using  two  or  three 
fillings   of  the  syringe,   retaining  the  injection  each 
time  for  two  or  three  minutes.     It  has  been  found 
that  the  antiseptics  suitable  for  urethral  use  require 
in  most  cases  a  minimum  of  ten  minutes  to  kill  the 
gonococcus.     It  is  true  that  the  urethral  surface  is 
left  moist  with  the  injection,  and  it  is  difficult  to 
estimate  exactly  how  long  the  antiseptic  action  will 
continue,  but  it  cannot  be  long  before  the  injected 
solution  becomes  diluted  with  exudation,  with  which, 
moreover,  it  may  react  chemically  and  be  rendered 
inert.    Retention  of  the  injection  is  therefore  advan- 
tageous so  long  as  the  reaction  which  follows  is  not 
greater  than  is  desired. 

As  a  rule,  injections  are  repeated  every  three  or 
four  hours,  and  whether  they  are  used  more  or  less 
frequently  will  depend  on  the  strength  of  the  solution 
employed,  the  acuteness  of  the  symptoms,  and  the 
occurrence  of  the  opportunity.  They  are  begun  as 
soon  as  gonococci  are  found,  and  used  continuously 
until  gonococci  have  disappeared  from  the  smears  and 
for  some  days  thereafter. 

During  the  night  a  long  interval  elapses  in  which 
neither  by  urination  nor  by  injection  is  there  any 
cleansing  of  the  urethra,  and  it  is  then  that  an 
extension  or  a  complication  is  most  likely  to  be 
excited,  especially  if  the  patient  is  troubled  with 
erections.  It  is  seldom  that  during  the  acute  stage  of 
gonorrhoea  an  unbroken  night's  rest  is  obtained,  and 
no  harm  but  much  good  is  got  if  the  patient  takes 


ACUTE   GONOCOCCAL   URETHRITIS     93 

advantage    of    the    restless    moment    to    empty    the 
bladder,  use  his  syringe,  and  have  a  drink  of  water. 

In  some  cases  either  hypersensitiveness  of  the 
urethra  or  the  irritating  nature  of  the  injection  will 
call  for  the  preliminary  use  of  a  local  anaesthetic.  As 
absorption  readily  occurs  from  the  urethral  canal, 
care  must  be  exercised  not  to  overdose  with  cocaine. 
One  or  two  drams  of  a  J  per  cent  solution  of  eucaine  or 
cocaine  may  be  employed  and  allowed  to  act  for  a 
few  minutes,  or  it  may  be  possible  to  include  anti- 
pyrene  as  an  anaesthetic  in  the  injection  prescribed. 
Permanganate  of  potash  produces  a  state  of  anaesthesia 
in  about  eight  minutes,  lasting  two  to  five  minutes, 
and  a  very  dilute  solution  might  be  suitable  for  use  in 
some  cases.  On  the  appearance  of  hyperacute 
symptoms,  it  may  be  necessary  to  withhold  all  kinds 
of  local  treatment  or  a  change  from  injections  to 
irrigation  with  a  mild  solution  may  be  indicated. 


REAGENTS   EMPLOYED   FOR   URETHRAL   INJECTIONS 

The  list  of  chemicals  which  have  been  used  as 
injections  is  a  long  one,  and  many  old-time  favourites 
are  forgotten.  Before  the  discovery  of  the  gonococcus, 
an  astringent  effect  was  the  one  quality  required  of 
an  injection.  They  are  now  valued  according  to  their 
antiseptic  action,  but  many  of  those  in  use  possess 
both  astringent  and  antiseptic  properties.  The 
following  table  is  far  from  complete,  and  new  injec- 
tions are  being  constantly  proposed,  which  proves 
that  perfection  in  the  technique  of  urethral  medication 
has  not  yet  been  attained. 


94    GONORRHCEA  &  ITS  COMPLICATIONS 

REAGENTS  EMPLOYED  FOR  URETHRAL  INJECTIONS 


strength  for  Injections. 


Strength  for  Instil-  !    Strengtli  for  In-igation 
lation.  i  and  Lavage. 


1.  Silver  Nitrate  .... 

2.  Silver  Fluoride  .  .  . 

3.  Actol  (silver  lac- 

tate)     

4.  Itrol  (citrate  of 

silver)    

5.  Silver  Iodide    .... 

6.  Argentide    (iodide 

of  silver,  100  gr. 
to  1  oz.) 

7.  Protargol    

8.  Argyrol 

9.  Largin  . 

10.  Albargin 

11.  Argentamin    

12.  Argonin 

13.  Nargol 

14.  Hegonon 

15.  Novargan 

16.  Iclithargan 

17.  Collargol    (colloid 

silver)    

18.  Colossal  Argentum 

19.  Ichthyol    

20.  Resorein 

21.  Salicylic  Acid  .... 

22.  Boric  Acid    

23.  Carbolic  Acid 

24.  Picric  acid    

25.  Citric  acid 

26.  Lactic  acid 

27.  Tannic  acid    

28.  Nitric  acid    

29.  BicMoride  of  Mer- 

cviry 

30.  Permanganate     of 

potash 

31.  Quinine  bisulphate   i 

32.  Thallin  sidphate    . 

33.  Hydrogen  peroxide 

34.  Iodine 

35.  Mercury  oxy cyanide 

36.  Alum 

37.  Copper  sulphate  .  . 

38.  Zinc  sulphate  .... 

39.  Zinc  sulphocarbo- 

late    

40.  Zinc  chloride    .... 

41.  Zinc  acetate 

42.  Nizin  (zinc  salt 

sulphanilic  acid) 

43.  Lead  acetate    .... 

44.  Bismuth  subnitrate 

45.  Bismuth  citrate  .  .    ! 


1  :  4,000  -1  :  2,000 
1  :  10,000-1  :  2,000 

1  :  10,000-1  :  4,000 

1  :  5,000  -1  :  2,000 
1  :  20    -1  :  10 


1  :  60    -1  :  30 
1  :  800   -1  :  100 
1  :  50    -1:5 
1  :  400   -1  :  100 
1  :  1,000  -1  :  100 
1  :  3,000  -1  :  500 
1  :  200   -1  :  30 
1  :  400   -1  :  100 
1  :400 

1  :  500   -1  :  50 
1  :  2,000  -1  :  500 

1  :  30        -1  :  20 
used  undiluted  as 

dispensed 
1  :  100      -1  :  20 
1  :  100      -1  :  25 
1  :  3,000  -1  :  2,000 
1  :  30        -1  :  16 
1  :  500      -1  :  250 
1  :  200      -1  :  100 
1  :  500      -1  :  250 
1  :  500      -1  :  200 
1  :  300      -1  :  200 


1  :  20,000-1  :  10,000 

1  :  3,000  -1  :  1,000 
1  :  1,000  -1  :  200 
1  :  250   -1  :  100 
1  :  100   -1  :  30 

1  :  6,000  -1  :  4,000 
1  :  500   -1  :  100 
1  :  500   -1  :  250 
1  :  500   -1  :  100 

1  :  500   -1  :  200 
1  :  2,000  -1  :  1.000 
1  :  500   -1  :  100 

1  :  240   -1  :  80 
1  :  250   -1  :  100 
1  :  50    -1  :  20 


1  :  500-1  :  100  1  :  10,000-1  :  4,000 


1  :  10,000-1  :  4,000 
1  :  2,000  -1  :  500 


1  :  20  -1  :  10 
1  :  200-1  :  50 


10 

50 

20 

100 

15 

20  -1 


1  :  5 


1  :  4,000  -1  :  2,000 

1  :  4,000  -1  :  2,000 

1 

1 

1 

1 


10 


1  :  20  -1  :  10 
1  :  300-1  :  100 


1  :400 


1,000  -1  :  250 
4,000  -1  :  1.000 
5,000  -1  :  1,000 
30,000-1  :  10,000 


1  :  4,000 

1  :  6,000  -1  :  2,000 
1  :  3,000  -1  :  1,000 
1  :  5,000  -1  :  2,000 

1  :  10,000 


1  :  5,000  -1  :  3,000 


1  :  5,000  -1  :  1,000 

1  :  30,000-1  :  20,000 

1  :  10,000-1  :  2,000 
1  :  5,000 


1  :  2,000  -1  :   500 
1  :  10,000-1  :  4,000 


1  :  3,000  -1  :  500 


ACUTE   GONOCOCCAL    URETHRITIS     95 

The  above  table  contains  no  drugs  which  are 
obsolete,  and  each  of  them  has  some  value.  They 
might  be  divided  into  stimulants,  sedatives,  anti- 
septics, and  astringents,  according  to  the  dominant 
feature  which  they  exhibit  when  applied  in  practice, 
but  most  of  them  duplicate  two  or  more  of  these 
functions.  Thus  the  silver  salts  and  silver  organic 
compounds  are  essentially  antiseptics  with  a  specific 
antigonococcal  action,  but  they  can  also  be  used  to 
stimulate  secretion  or  to  produce  an  astringent  effect 
if  applied  in  suitable  concentrations.  Bismuth  sub- 
nitrate  is  sedative  and  to  some  extent  astringent, 
while  zinc  sulphate  is  used  only  for  its  astringent 
action.  A  selection  of  half  a  dozen  or  less  of  these 
medicaments  will  fulfil  all  requirements  provided  the 
action  and  dosage  of  each  is  mastered  in  detail.  It  is 
better  to  have  a  complete  working  knowledge  of  a 
few  preparations  than  a  hazy  appreciation  of  a  large 
number.  One  of  the  organic  silver  compounds  of 
which  protargol  may  be  taken  as  a  type  is  indis- 
pensable in  the  injection  treatment  of  urethritis  ; 
nitrate  of  silver  is  essential  in  the  declining  stage  in 
some  cases  ;  permanganate  of  potash  is  more  gener- 
ally useful  than  any  other  individual  drug,  and  to 
complete  an  outfit  an  astringent  such  as  sulphate  of 
zinc  might  be  included. 

Nitrate  of  silver  for  many  years,  in  fact  since 
Ricord's  time,  held  the  first  place  in  the  injection 
treatment  of  gonorrhoea.  Neisser  proved  its  anti- 
septic powers  over  the  gonococcus,  and  confirmed 
Ricord's  estimate  of  its  clinical  value.  It  has  not 
escaped  criticism.  It  has  been  blamed  as  being  re- 
sponsible for  the  production  of  a  considerable  pro- 
portion of  the  strictures  which  are  such  a  frequent 
sequel  of  an  attack  of  gonorrhoea.     The  substitution 


96    GONORRHEA  &  ITS  COMPLICATIONS 

of  the  organic  silver  combinations  in  place  of  the 
nitrate  has  certainly  reduced  the  danger  of  stricture 
formation.  But  even  before  the  day  of  protargol 
and  its  fellows,  a  reduction  in  the  prescribed  solution 
of  the  nitrate  to  below  the  laboratory  bactericidal 
strength  had  enabled  many  clinicians  to  avoid  the 
disastrous  after-effects  of  the  drug  while  retaining  its 
curative  powers.  It  is  now  used  only  in  concentra- 
tions of  from  1  in  6000  to  1  in  2000,  except  when 
wanted  for  an  occasional  application  to  small  areas 
on  the  wall  of  the  canal,  where  solutions  of  2  to  5 
per  cent  may  be  used  provided  an  interval  of  several 
days  elapses  between  each  treatment.  Solutions 
must  either  be  prepared  with  distilled  or  rain  water, 
or  allowance  must  be  made  in  calculating  the  strength 
for  the  counteracting  effect  of  the  chlorides  present 
in  the  water.  London  water  renders  inert  about 
1  gr.  per  pint  (Wyndham-Powell). 

Protargol  is  one  of  the  protein  silver  compounds. 
It  does  not  coagulate  albumen  and  is  not  precipi- 
tated by  sodium  chloride.  It  is  decomposed  by  heat, 
and  must  therefore  be  prepared  and  used  in  the  cold. 
Neisser  suggested  one  injection  to  be  retained  for 
thirty  minutes,  and  two  others  of  five  minutes'  dura- 
tion as  the  daily  treatment.  He  recommended  the 
prolonged  application  of  the  solution,  hoping  thereby 
to  obtain  a  deeply  penetrating  effect.  One  long- 
continued  injection  is  more  irritating  than  three 
injections  of  moderate  duration,  say  five  to  ten 
minutes.  Ten  or  at  most  twenty  minutes  is  now  the 
time  generally  allowed,  and  two  or  three  changes  of 
the  solution  in  the  urethra  is  practised.  Protargol  is 
unirritating  in  concentrations  below  1  per  cent,  but 
in  acute  urethritis  it  is  wise  to  begin  with  |  per  cent 
or  J  per  cent.     Some  authorities  prefer  to  see  the 


ACUTE   GONOCOCCAL    URETHRITIS     97 

patient  daily,  when  they  administer  an  injection  of 
a  strong  solution  containing  a  local  anaesthetic.  Thus 
Neisser  now  employs  in  this  way  a  solution  of  pro- 
targol  3  per  cent  and  antipyrine  5  per  cent,  retained 
twenty  minutes  ;  while  the  patient  is  instructed  to 
use  at  home  other  two  injections  of  a  solution  of 
protargol  J  per  cent  plus  3  per  cent  antipyrine,  re- 
tained for  five  minutes.  Neisser  admits  that  this 
treatment  is  liable  to  irritate  even  to  the  extent  in 
some  cases  of  inducing  a  bloodstained  discharge. 
These  strong  solutions  have  therefore  not  found 
general  favour,  and  better  results  are  achieved  and 
with  much  less  discomfort  to  the  patient  by  be- 
ginning with  weak  solutions  and  gradually  increasing 
the  strength. 

Novargan,  an  albuminate  of  silver,  is  reported  to 
be  less  irritating  than  protargol.  A  suitable  strength 
for  injection  is  from  J  to  2  per  cent. 

Argyrol,  another  albumen  compound  (silver  vitel- 
lin),  is  probably  the  least  irritating  of  all,  on  which 
account  it  can  be  used  in  much  stronger  solutions 
even  up  to  20  per  cent.  A  good  working  concentra- 
tion is  5  per  cent.  It  has  the  disadvantage  of  staining 
the  hands,  linen,  etc.,  but  the  stains  can  be  de- 
colorised by  immersion  in  1  in  500  bichloride  of 
mercury.  It  is  less  efficient  as  a  laboratory  antiseptic 
than  the  other  silver-albumen  combinations,  but  on 
account  of  its  cleansing  action  it  is  useful  for  removing 
purulent  secretion. 

Largin  is  similar  in  composition  and  action  to  pro- 
targol. 

Alhargin  is  a  combination  of  silver  nitrate  and 
gelatine.  It  is  a  soluble  white  powder,  and  the  solu- 
tions are  comparatively  stable.  As  it  dialyses  through 
animal  membranes  it  is  said  to  have  a  deep  penetra- 

WATSON. — H 


98    GONORRHCEA  &  ITS  COMPLICATIONS 

tive  action.  A  solution  of  from  0-1  to  1  per  cent  is 
employed. 

Ichthargan,  an  ichthyol-silver  compound,  can,  on 
account  of  its  low  cost,  be  used  for  irrigations  as  well 
as  injections.  For  injections  the  strength  should  be 
from  0-02  to  0-2  per  cent.  Both  ichthyol  and  ichthar- 
gan are,  as  a  rule,  unirritating,  but  in  occasional  cases 
a  considerable  inflammatory  reaction  is  produced, 

Nargol  is  a  chemical  combination  of  silver  with 
nucleinic  acid  from  yeast.  Solutions  of  from  0-25  to 
1  per  cent  are  injected. 

Argentide  is  iodide  of  silver  in  fine  suspension  ready 
for  dilution.  Iodide  of  silver  being  insoluble  should  be 
prescribed  as  Argentide,  or  in  a  mucilaginous  mixture. 

The  silver  solutions  should  be  fresh,  and  therefore 
only  small  quantities  should  be  prescribed.  They 
should  be  prepared  with  distilled  water,  dispensed  in 
dark-coloured  bottles,  and  protected  from  the  light. 
As  most  of  the  organic  salts  are  decomposed  by  heat, 
they  should  not  be  diluted  with  hot  water.  It  is 
better  to  prescribe  a  solution  of  the  exact  strength 
to  be  injected,  and  sufficient  warmth  can  be  ensured 
by  the  patient  carrying  the  vial  in  his  pocket. 

The  doses  given  in  the  appended  table  are  in  most 
instances  lower  than  many  practitioners  are  in  the 
habit  of  prescribing,  and  it  is  not  always  necessary 
to  begin  with  the  lowest  percentage.  It  is,  however, 
safer  to  err  on  the  side  of  moderation  in  this  respect 
than  to  attempt  to  abort  the  disease  by  using  con- 
centrations which  might  excite  an  excessive  reaction 
and  induce  complications.  Over-treatment  is  un- 
doubtedly dangerous,  and  has  to  be  as  carefully 
avoided  as  timorous  treatment.  Only  careful  super- 
vision of  each  case  with  the  aid  of  the  microscope  can 
decide  the  correct  course  to  pursue. 


ACUTE   GONOCOCCAL    URETHRITIS     99 

Many  reports  of  laboratory  experiments  to  test 
the  bactericidal  power  of  the  different  antiseptics  in 
use,  with  special  reference  to  the  gonococcus,  have 
been  published.  The  most  contradictory  results  have 
been  obtained,  due  in  some  instances  to  difference 
in  technique.  The  negative  results  obtained  with  the 
organic  silver  preparations  by  some  American  workers 
are  meantime  insufficient  to  outweigh  the  strong 
evidence  in  favour  of  their  antiseptic  properties 
obtained  by  many  careful  investigators  in  Germany 
and  elsewhere.  In  any  case,  the  clinical  evidence  is 
overwhelmingly  in  favour  of  the  albumen-silver 
compounds  in  particular.  It  is  impossible  to  create 
in  the  laboratory  exactly  the  conditions  obtaining  in 
the  urethra,  "  the  living  culture  tube."  The  urethral 
exudate  contains  antibodies  which  are,  of  course, 
absent  from  the  culture  tube  used  experimentally, 
and  this  may  be  one  of  the  features  determining  the 
susceptibility  of  the  gonococcus  to  the  silver  salts. 

The  effect  of  the  injection  is  therefore  (1)  to  destroy 
or  at  least  weaken  the  gonococci  with  which  it  comes 
into  contact ;  (2)  to  alter  the  urethral  mucous  mem- 
brane in  such  a  manner  as  to  render  it  an  unsuitable 
medium  for  the  growth  of  the  gonococcus  ;  (3)  to 
mechanically  cleanse  the  urethra.  The  cleansing 
effect  is  of  minor  importance  in  this  method  of  treat- 
ment. If  this  were  the  object  in  view,  injection  of 
small  quantities  of  viscid  fluid  would  not  be  the 
means  which  would  suggest  itself.  Possibly  the  most 
important  result  of  the  injection  is  the  change  which 
it  produces  in  the  urethral  mucosa.  There  is  here 
still  a  field  for  useful  investigation,  and  meantime 
the  clinical  results  must  be  accepted  as  deciding  in 
favour  of  the  value  of  the  silver  compounds. 


100    GONORRH(EA  &  ITS  COMPLICATIONS 

URETHRO-VESICAL   LAVATIONi 

To  Janet  belongs  the  credit  of  perfecting  and  popu- 
larising the  method  of  urethro-vesical  lavation  by 
hydrostatic  pressure,  which  he  calls  "  Grand  Lavage." 
The  kernel  of  his  teaching  is  that  no  irrigating  instru- 
ment should  be  passed  along  the  canal,  but  that  both 
an  inward  and  an  outward  rinsing  of  the  entire  tract 
should  be  obtained  by  filling  the  bladder  from  a 
column  of  solution  having  sufficient  pressure  to  over- 
come, with  certain  adventitious  aids,  the  resistance  of 
the  sphincter  muscles.  It  might  be  objected  that  by 
this  procedure  we  are  violating  the  sanctuary  of  the 
posterior  urethra,  a  risk  we  take  precautions  to 
avoid  when  practising  urethral  injections.  The  con- 
ditions in  the  two  cases  are,  however,  entirely  dif- 
ferent. In  the  first  place,  in  injecting  a  small  quantity 
of  fluid  into  the  urethra  the  portion  w^hich  finds  its 
way  behind  the  compressor  urethrse  is  retained  there, 
and  it  may  have  carried  before  it  a  droplet  of  pus 
collected  in  the  bulb  between  the  previous  act  of 
micturition  and  the  actual  injection.  Again,  the 
antiseptic  may  not  be  intimately  mixed  with  the 
infective  secretion. 

On  the  other  hand,  in  lavation  the  anterior  urethra 
is  thoroughly  washed  free  of  all  secretion  with  a  large 
quantity  of  antiseptic  fluid  (500  c.c.)  immediately 
before  entrance  to  the  posterior  urethra  is  at- 
tempted, and  any  organisms  finding  their  way  into 
the  posterior  tract  are  expelled  on  the  completion  of 
the  operation  by  the  patient  clearing  his  bladder  of 

1  The  revival  of  this  almost  obsolete  term  is  I  think  justified  by  the  diffi- 
culty of  expressing  in  English  exactly  what  Janet  means  by  "  Grand  Lavage" 
and  the  confusion  which  is  apt  to  arise  when  the  words  "washing/'  "rins- 
ing," or  irrigation  "  are  used. 


ACUTE   GONOCOCCAL    URETHRITIS     101 

its  contents.  Any  stray  cocci  which  may  obtain  a 
lodgment  in  a  crevice  of  the  posterior  urethra  or  of 
the  bladder  will,  if  still  capable  of  seeking  a  live- 
lihood, find  a  very  uncongenial  soil  in  a  mucous 
membrane  saturated  with  permanganate.  However, 
the  real  test  is  clinical  experience,  and  it  is  not 
maintained  by  any  careful  observer  who  has  given  a 
sufficient  trial  to  this  method  of  treatment  that  it  in- 
creases the  risk  of  posterior  urethritis  and  its  compli- 
cations. On  the  contrary,  one  of  the  advantages 
claimed  for  lavation  is  that  not  only  does  it  greatly 
increase  the  patient's  comfort,  but  that  the  incidence 
of  posterior  extension  is  considerably  reduced. 

The  one  blemish  which  detracts  from  the  general 
usefulness  of  this  treatment  is  the  natural  disinclina- 
tion of  a  busy  practitioner  to  undertake  the  somewhat 
arduous  and  time-consuming  task.  Where  there  is 
a  sequence  of  cases  to  be  treated  and  special  apparatus 
and  accommodation  can  therefore  be  afforded,  no 
other  treatment  will  give  the  same  satisfaction  either 
to  the  patient  or  practitioner. 

\^'Tien  a  patient  enters  consulting  -  rooms  where 
there  are  no  conveniences  suitable  for  the  examina- 
tion and  treatment  of  acute  gonorrhoea,  the  surgeon 
naturally  dislikes  to  properly  examine  the  patient, 
let  alone  treat  him.  The  prospect  of  drops  of  pus 
falling  on  the  carpet,  or  pus-contaminated  hands 
fingering  the  furniture  or  door-handle,  makes  the 
unfortunate  patient  too  often  an  unwelcome  intruder, 
and  the  fight  between  the  doctor's  conscience  and  his 
feelings  one  in  which  the  right  may  not  always  win. 
Every  surgeon  who  is  going  to  undertake  such  cases, 
and  no  more  interesting  and  unwrought  field  of  work 
is  now  open  to  the  medical  profession,  ought  to  make 
such  arrangements  for  the  reception  of  these  cases  as 


102    GONORRHCEA  &  ITS  COMPLICATIONS 


will  ensure  an  aseptic  performance  both  of  diagnosis 
and  treatment.  This  involves  the  installation  of  at 
least  one  special  apartment  furnished  and  fitted  on 

hospital  lines.  The  floor 
is  covered  with  linoleum, 
the  chairs  and  couch  are 
white  enamelled  iron.  An 
instrument  cupboard,  one 
or  two  aseptic  tables  with 
lockers,  a  wash-hand  basin, 
an  enamelled  slop  pail,  and 
an  irrigating  apparatus  on 
stand  or  pulley  (Fig.  26) 
complete  the  major  part  of 
the  outfit. 

For  the  purpose  of  wash- 
ing out  the  urethral  tract 
by  Janet's  method,  the 
patient,  after  urinating  and 
having  sufficiently  un- 
dressed, lies  on  the  couch 
with  a  urological  basin 
(Fig.  27)  between  the 
thighs.  The  reservoir  con- 
taining a  litre  of  warm 
solution  is  hoisted  so  as  to 
rest  from  3|-  to  5  feet  above 
the  level  of  the  table.  The 
region  of  the  prepuce  and 
glans  having  been  thor- 
oughly cleansed  with  swabs 
and  antiseptic  lotion,  the  urethral  canula  (Fig.  28) 
is  inserted,  the  tap  partly  turned  forwards,  and  the 
anterior  urethra  is  gently  filled  to  complete  disten- 
sion and  then  emptied  several  times  in  succession. 


Fig,  26. 


ACUTE   GONOCOCCAL    URETHRITIS     103 


About  half  of  the  solution  is  utilised  in  this  way  and 
the  bladder  is  then  filled.  To  accomplish  this  the 
patient  is  told  to  relax  his  muscles,  breathe  deeply, 
and  make  gentle  efforts  as 
if  to  urinate,  and  the  full 
pressure  of  the  irrigator  is 
turned  on.  It  will  then  be 
found,  if  successful,  that  the 
solution  is  flowing  into  the 
bladder,  and  when  com- 
plaint of  fullness  is  made 
the     canula     is     withdrawn, 

and  the  patient  expels  the  bladder  contents.  The 
permanganate,  when  this  salt  is  used,  will  be  found 
to  have  been  more  or  less  reduced,  as  evidenced  by 
its  colour,  according  to  the  proportion  of  urine  with 
which  it  has  been  mixed. 


Fig.  2r. 


Fig.  28- 


If  the  attempt  is  not  successful  it  is  due  to  the 
hypercontraction  of  the  compressor  urethrse  either 
from  the  reflex  stimulation  of  a  too  cold  solution,  a 
hypersensitive  urethra,  or  spasmodic  contraction  in 


104    GONORRH(EA  &  ITS  COMPLICATIONS 

a  nervous  patient.  The  temperature  of  the  solution 
should  be  above  lukewarm,  but  not  hot,  100°  to 
104°  F.  A  second  attempt  may  succeed  when  the 
patient  understands  better  what  is  required  of  him. 
Rarely  is  a  local  anaesthetic  required,  although  many 
surgeons  make  this  a  routine  procedure,  using  two 
drams  of  a  1  per  cent  solution  of  eucaine  lactate  or 
stovaine,  which  is  retained  in  the  urethra  for  five 
minutes,  and  part  of  it  insinuated  into  the  posterior 
urethra  by  digital  manipulation. 

Many  of  the  criticisms  which  one  reads  of  the 
"  irrigation  "  method  are  really  aimed  at  irrigation 
confined  to  the  anterior  urethra.  The  results  of 
anterior  irrigation  are  not  good.  The  posterior 
urethra  frequently  becomes  involved,  and  not  only 
does  it  remain  untreated,  but  the  spasm  induced  by 
prolonged  anterior  irrigations  tends  to  increase  the 
acuteness  of  the  symptoms  and  to  incite  complica- 
tions. 

Lavation,  like  all  other  forms  of  local  treatment,  is 
contra-indicated  in  hyperacute  cases,  but  otherwise 
there  is  no  reason  to  withhold  it  in  any  stage  of  ure- 
thritis. 

Solutions  employed  in  Lavation 

Potassium  permanganate. — The  agent  which  is  most 
generally  useful  is  permanganate  of  potash  in  con- 
centration of  from  1  :  10,000  to  1  :  4000  and  rarely 
1  :  2000.  Beginning  with  the  weakest  solution,  daily 
or  twelve-hourly  treatments  are  continued  with 
gradual  successive  increases  in  the  strength  until  all 
discharge  has  disappeared  and  the  urine  is  clear. 
Usually  this  occurs  within  a  fortnight,  and  thereafter, 
in  the  absence  of  the  gonococcus  from  the  smears, 
the   lavations    can   be   given    with   two,    three,    and 


ACUTE   GONOCOCCAL    URETHRITIS     105 

seven  day  intervals  respectively.  Repeating  the 
treatment  twice  a  day  is,  as  a  rule,  only  feasible 
when  the  patient  can  be  taught  to  carry  out  the 
process  himself,  and  this  will  seldom  be  found  practic- 
able. 

The  more  frequent  the  irrigations  the  weaker 
should  be  the  solution.  The  1  :  2000  concentration 
is  seldom  called  for,  and  never  in  acute  lU'ethritis. 
With  1  :  4000  we  should  be  able  to  finish  the  treat- 
ment satisfactorily.  No  after-effects  should  be  felt 
by  the  patient  other  than  a  slight  sensation  of  heat 
lasting  for  perhaps  an  hour. 

A  concentrated  solution  of  sodium  bisulphite  or  of 
oxalic  acid  will  remove  the  stains  on  hands  or  cloth- 
ing produced  by  permanganate. 

Albargin,  1  in  2000,  may  be  substituted  for  the 
permanganate  for  a  few  days  in  refractory  cases. 
Other  salts  which  may  be  employed  are  included  in 
the  table  on  page  94. 

Lavation  by  means  of  a  large  syringe. — According 
to  the  French  literature  it  would  seem  that  their 
surgeons  have  seldom  or  never  any  difficulty  in 
practising  "  grand  lavage."  This  is  doubtless  largely 
owing  to  expertness  resulting  from  experience,  but 
it  is  possibly  also  due  to  some  extent  to  the  facility 
with  which  the  patients  can  comply  with  instructions. 
Whatever  the  explanation,  there  is  certainly  found  in 
this  country  a  small  proportion  of  cases  where  no 
patience  or  expedient  will  get  the  fluid  past  the 
sphincter.  On  this  account  it  is  well  to  be  supplied 
with  a  large  syringe  (100-150  c.c.)  with  which  the 
procedure  can  be  completed.  A  carefully  made 
instrument  with  metal  plunger  and  finger  loops  is 
illustrated  in  Fig.  29 ;  a  rubber  tip  and  metal 
or  vulcanite  shield  are  necessary  additions.    In  using 


106    GONORRHCEA  &  ITS  COMPLICATIONS 

this  syringe  the  motive  is  to  insinuate  the  solution 
into  the  posterior  urethra,  whence  it  gains  the  bladder, 
by  sudden  short  plunges  during  quiescent  condi- 
tions of  the  sphincter.  At  other  times  the  solution 
will  enter  without  difficulty  on  continuous  pressure 
being  exerted,  but  care  must  be  exercised  to  avoid 
forcing  a  passage.  It  is  no  use  fighting  the  sphincter, 
it  has  to  be  "  dodged."  A  delicate  touch  can  readily 
appreciate  the  condition  of  the  sphincter.  Our  con- 
trol over  the  action  of  the  syringe  is  complete,  and 
as  we  can  vary  the  amount  and  incidence  of  the 
pressure  as  required,  a  large  syringe  is  a  valuable 
addition  to  our  armamentarium. 


Fig.  29, 
Albarran's  vesical  syringe. 

Whether  the  reservoir  or  the  large  syringe  is  em- 
ployed, the  whole  procedure  must  be  carried  out  in 
such  a  systematic  and  gentle  manner  that  no  injury 
is  done  to  the  inflamed  mucosa.  If  there  is  any 
doubt  as  to  our  ability  to  avoid  traumatism,  or  if 
pain  be  complained  of,  this  method  should  be 
abandoned  and  recourse  had  to  small  syringe  in- 
jections. 

No  instrument  can  be  allowed  to  penetrate  the 
posterior  urethra  during  the  progress  of  an  acute 
urethritis,  therefore  filling  the  bladder  by  means  of  a 
catheter  or  other  irrigating  instrument  which  passes 
through  the  sphincter  is  unwarrantable.  Complica- 
tions and  extensions  are  invited  by  such  treatment. 


ACUTE   GOXOCOCCAL    URETHRITIS     107 

The  routine  use  of  rectal  suppositories  of  atropine 
sulphate,  as  practised  by  Schindler,  in  doses  of  1/75 
of  a  grain  twice  daily,  reduces  to  a  minimum  the 
dangers  of  vesiculitis  and  epididymitis,  and  is  there- 
fore to  be  recommended. 

ABORTIVE   TREATMENT 

Provided  that  the  gonococcus  is  found  in  the  ure- 
thra before  the  appearance  of  a  purulent  discharge, 
it  may  be  possible,  by  the  adoption  of  espe- 
cially energetic  measures,  to  prevent  the  develop- 
ment of  an  acute  urethritis.  When  the  case  comes 
under  observation  more  than  twenty-four  hours  after 
the  onset  of  the  first  symptoms,  the  prospects  of 
success  are  remote  ;  but  no  absolute  time  limit  can 
be  stated.  The  only  criterion  is  the  degree  of  inflam- 
mation presented.  When  the  appearance  of  the 
meatus  is  normal,  and  the  small  quantity  of  gonococ- 
cus-bearing  discharge  which  can  be  expressed  is 
mucoid  in  character,  an  attempt  to  abort  the  disease 
should  be  made.  A  short  incubation  period  is  an 
unfavourable  indication,  as  it  suggests  either  a  weak 
resistance  on  the  part  of  the  patient  or  a  special 
virulence  of  the  particular  strain  of  gonococcus. 
Suitable  cases  are  seldom  seen  in  dispensary  work,  but 
in  private  practice  the  number  of  patients  seeking 
advice  soon  after  an  indiscretion  is  increasing  with 
the  spread  of  a  clearer  conception  of  the  symptoms 
of  the  disease. 

It  must  be  distinctly  understood  that  in  speaking 
now  of  abortive  treatment  we  refer  simply  and  solely 
to  an  attempt,  not  to  cut  short  an  urethritis  already 
in  being,  but  to  stamp  out  the  infection  before  it  can 
give  rise  to  its  characteristic  acute  inflammatory  re- 
action.   Abortive  treatment,  wrongly  so  called,  when 


108    GONORRHCEA  &  ITS  COMPLICATIONS 

aimed  at  the  suppression  of  an  already  present  acute 
gonorrhoea,  is  not  only  unwise  on  account  of  the  pain- 
fulness  of  the  procedure,  but  frequently  disastrous 
both  in  its  immediate  and  remote  effects.  The  whole 
raison  d'etre  of  abortive  treatment  is  based  on  a 
reasonable  hope  that  the  gonococcus  has  not  pene- 
trated beyond  reach  of  the  antiseptic,  and  that  the 
whole  family  of  invaders  can  be  destroyed.  It  is  a 
very  attractive  proposition,  but  unfortunately  it  is 
not  sufficiently  often  realised  in  practice,  and  in  the 
event  of  failure  many  of  the  recommended  treatments 
have  an  unfavourable  influence  on  the  course  of  the 
gonorrhoea.  It  must  be  accepted  that  no  method 
of  abortive  treatment  is  justifiable  which  in  the  event 
of  non-success  will  increase  the  acuteness  of  the 
sequent  gonorrhoea. 

Every  case  in  which  the  gonococcus  has  been  im- 
planted in  the  urethra  does  not  develop  into  an  acute 
urethritis.  Thus  it  has  frequently  been  noticed,  that 
of  several  men  cohabiting  with  the  same  infected 
female,  one  or  more  suffer  from  an  acute  attack  of 
urethritis,  while  others  remain  free  from  symptoms. 
Of  those  who  escape  the  probability  is  that  some 
are  "  carriers  "  of  the  gonococcus,  but  being  pos- 
sessed of  a  relative  immunity  they  successfully  resist 
the  gonococcus,  which  sooner  or  later  disappears  from 
the  urethra  without  having  produced  symptoms.  A 
proportion  of  the  reported  cures  credited  to  abortive 
treatment  are  doubtless  cases  belonging  to  this  cate- 
gory, but  even  so  these  "  carrier  "  cases  require  to 
have  their  urethras  sterilised,  and  the  sooner  the 
better.  One  cannot  question  the  possibility  of  abor- 
tive treatment  being  really  successful  in  a  proportion 
of  cases,  provided,  as  already  said,  the  treatment  is 
initiated  sufficiently  early. 


ACUTE   GONOCOCCAL    URETHRITIS     109 

The  method  most  generally  useful  in  this  connection 
is  the  injection  into  the  anterior  urethra  by  means  of 
a  small  syringe  of  a  comparatively  strong  solution  of 
one  of  the  organic  silver  compounds.  Taking  pro- 
targol  as  a  standard,  immediately  on  the  diagnosis 
being  completed  an  injection  of  a  1  to  2  per  cent 
solution  is  undertaken,  the  injection  being  continued 
for  ten  minutes  with  one  or  two  intervals  for  renewal. 

The  first  injection  should  be  of  the  maximum 
strength  and  of  the  maximum  duration  which  the 
patient  can  bear  without  much  discomfort,  as  in 
abortive  treatment  the  initial  injection  is  the  most 
important.  The  concentration  and  duration  of  the 
succeeding  injections  will  be  determined  by  the  re- 
action which  has  taken  place  in  the  interval.  The 
injection,  if  well  borne,  should  be  repeated  twice 
daily  for  three  days,  when  it  is  reduced  to  J  to  1 
per  cent.  This  should  be  combined  with  the  adminis- 
tration of  atropine  suppositories  (1/75  grain)  night  and 
morning,  and  15  grains  of  urotropine  or  other  urinary 
antiseptic  along  with  a  copious  intake  of  fluids  and 
the  usual  restrictions  as  to  diet  and  exercise. 

These  injections  should  be  performed  by  the  medi- 
cal attendant,  and  should  only  be  repeated  in  the 
absence  of  pronounced  inflammatory  reaction.  If 
necessary  the  intervals  between  injections  are  ex- 
tended or  the  retention  periods  reduced. 

Protargol  is  perhaps  not  the  best  preparation  for 
this  type  of  treatment.  One  of  the  less  irritating 
compounds  would  be  more  suitable.  Thus  10  per  cent 
argyrol  or  5  per  cent  novargan,  preferably  the  latter, 
might  be  substituted. 

Where  success  has  been  achieved  it  may  be  antici- 
pated that  the  gonococcus  will  have  disappeared 
from  the  smears  by  the  second  or  third  day  of  treat- 


110    GONORRHCEA  &  ITS  COMPLICATIONS 

ment ;  but  as  there  are  probably  still  some  pus 
flakes  to  be  seen  in  the  first  urine  glass,  the  injections 
of  the  weaker  concentration  should  still  be  continued 
for  two  or  three  days,  when  all  treatment  may  be 
suspended  in  the  absence  of  symptoms.  The  patient 
should,  of  course,  be  kept  under  observation  during 
the  following  weeks,  and  instructed  as  to  the  appear- 
ances which  would  act  as  a  warning  of  threatened 
recurrence. 

One  precaution  which  requires  the  strictest  ob- 
servance is  surgical  cleanliness  of  the  urethral  canal. 
To  allow  the  meatus  after  an  abortive  injection  to 
come  into  contact  with  an  unclean  prepuce  or  a 
stained  shirt  would  make  the  whole  performance 
futile.  The  glans,  coronal  sulcus,  and  prepuce  must 
be  carefully  sterilised  with  oxycyanide  of  mercury 
1  :  1000,  followed  by  the  silver  solution.  The  penis 
is  wrapped  in  a  gauze  dressing,  and  the  patient  is 
directed  to  change  his  underclothing  and  linen 
immediately,  and  use  a  fresh  gauze  dressing  each 
time  he  urinates. 

Abortive  lavation. — In  a  percentage  of  cases  which 
is  estimated  as  high  as  25  per  cent  in  the  opinion  of 
some  observers,  the  posterior  urethra  is  involved 
from  the  first  day,  and  therefore  any  treatment 
which  does  not  include  the  posterior  division  of  the 
canal  will  in  these  cases  be  ineffectual.  On  this 
account,  Janet  and  his  followers,  when  practising 
abortive  treatment,  adopt  lavage  with  strong  per- 
manganate solutions  frequently  repeated. 

Lebreton's  results  show  that  when  suitable  cases 
are  chosen  strong  solutions  are  unnecessary.  He 
advises  concentrations  of  from  1  :  5000  to  1  :  10,000, 
repeated  every  twelve  hours  for  four  days  and  every 
twenty-four  hours  for  other  four  days.     In  addition 


ACUTE    GONOCOCCAL    URETHRITIS     111 

to  these  "  grand  lavage  "  treatments,  he  asks  the 
patient  to  syringe  the  anterior  urethra  several  times 
in  succession  with  weak  permanganate  after  each 
micturition.  Performed  in  this  manner,  lavation  is 
without  risk  and  promises  well. 

Oxycyanide  of  mercury  or  one  of  the  silver  com- 
pounds may  be  used  instead  of  permanganate  of 
potash,  so  long  as  solutions  which  produce  irritation 
are  avoided. 

Treatment  of  urethritis  by  ajjplying  heat  to  the  ure- 
thra.— The  fact  that  a  temperature  of  44°  C.  main- 
tained for  ten  to  twenty  minutes,  or  of  45°  C.  for  one 
minute,  is  sufficient  to  destroy  some  cultures  of  the 
gonococcus  naturally  led  to  attempts  to  utilise  this 
laboratory  observation  in  practice. 

\'\Tiile  a  few  first  reports  of  the  use  of  special 
electrically-heated  appliances  have  been  enthusiastic, 
a  larger  experience  failed  to  confirm  the  hopes  as  to 
their  value.  The  failure  was  due  to  the  impossibility 
of  attaining  more  than  a  superficial  action  of  the 
heat,  and  to  the  heat-resisting  powers  of  some  strains 
of  gonococci.  The  rapidly  circulating  blood  stream 
prevents  the  tissues  being  affected  to  the  requisite 
degree.  Some  recent  reports  seem  to  indicate  that 
it  may  still  be  found  possible  to  make  this  method 
therapeutically  useful.  It  might  be  worthy  of  trial 
as  an  abortive  treatment  in  the  early  stages  of  an 
anterior  urethritis  in  conjunction  with  the  applica- 
tion of  a  tourniquet  to  the  root  of  the  penis,  and  in 
the  later  stages  in  conjunction  possibly  with  vaccine 
treatment. 

There  are  two  types  of  appliance  for  urethral 
thermotherapy  :  (a)  electrically-heated  bougies,  and 
(h)  double-channel  catheters  for  the  circulation  of 
hot  water.     The  apparatus  and  the  method   of  its 


112    GONORRHCEA  &  ITS  COMPLICATIONS 

application  will  be  described  under  the  treatment  of 
chronic  urethritis. 

The  use  of  Bier^s  hypercemia  in  acute  gonorrhoea  has 
been  favourably  reported  upon  by  Miles,  of  Edin- 
burgh. A  special  vacuum  chamber  is  manufactured 
for  the  purpose  of  receiving  the  penis.  The  conges- 
tion is  maintained  for  one  hour  with  intervals  of  re- 
laxation every  twenty  minutes,  and  the  treatment  is 
applied  daily.  The  results  reported,  while  good,  are 
not  better  than  can  be  obtained  by  less  cumbersome 
methods,  and  the  danger  of  systematic  infection  is 
probably  increased  by  the  adoption  of  this  method 
of  treatment. 

The  insertion  of  medicated  bougies. — Bougies  made 
with  a  cocoa-butter  or  glyco-gelatine  base  and  con- 
taining protargol,  nargol,  or  another  of  the  silver 
compounds,  have  been  somewhat  extensively  used  ; 
but  as  their  retention  is  liable  to  incite  complications 
and  posterior  extensions,  they  should  be  employed 
with  great  reserve,  especially  in  acute  conditions. 

TREATMENT   OF  ACUTE   POSTERIOR   URETHRITIS 

The  mucosa  of  the  posterior  urethra  presents  a  soil 
less  fertile  than  that  of  the  anterior  for  the  growth 
of  the  gonococcus.  Uncomplicated  gonococcal  inflam- 
mation of  the  posterior  urethra  is  in  consequence 
more  amenable  to  treatment,  especially  prophylactic 
treatment.  In  fact,  it  tends  to  spontaneous  cure  in 
from  ten  to  fourteen  days. 

Posterior  urethritis  owes  its  importance  to  the 
fact  that  from  it  originates  the  great  majority  of  the 
complications  to  which  gonococcus-infected  patients 
are  liable,  and  the  treatment  is  dominated  by  this 
consideration. 


ACUTE   GONOCOCCAL    URETHRITIS     113 

More  or  less  involvement  of  the  prostatic  ducts  is 
present  in  all  cases,  and  whether  or  not  this  will  give 
rise  to  symptoms  of  prostatitis  and  thus  constitute 
a  complication,  will  depend  on  the  depth  to  which 
the  process  extends.  The  ejaculatory  ducts  and  the 
prostatic  utricle  are  also  liable  to  attack,  and  the 
latter  especially  is  likely  to  become  a  site  of  chronic 
disease  unless  the  inflammation  is  checked  by  early 
treatment. 

The  treatment  which  should  be  adopted  depends 
on  the  condition  of  the  parts  when  the  case  first 
comes  under  observation.  The  local  treatment  must 
be  performed  wholly  by  the  medical  attendant. 

Hyperacute  cases  in  which  in  addition  to  the 
symptoms  of  a  florid  anterior  urethritis  there  is  con- 
siderable pus  in  the  second  urine  glass,  frequent 
painful  micturition,  tenderness  and  terminal  hsema- 
turia,  require  complete  rest  in  bed.  All  local  treat- 
ment should  be  postponed  for  some  days.  Urinary 
antiseptics  are  given  internally.  Sandal-wood  oil  in 
10  m.  capsules,  giving  four  to  six  each  day,  is  of 
considerable  advantage,  but  is  preferably  withheld 
during  the  first  two  days  of  treatment.  Hot  rectal 
douches  through  a  prostatic  rectal  tube  and  pro- 
longed sitz  baths  are  of  great  value  in  relieving  the 
dysuria  and  tenderness. 

The  insertion  night  and  morning  of  atropine 
suppositories,  1/75  of  a  grain  in  each,  relieves  spasm, 
and  reduces  the  risk  of  extension  to  the  vesiculae 
seminales  and  epididymes  ;  or  to  ensure  more  rapid 
action  and  accurate  dosage  the  atropine  may  be 
given  hypodermically.  Morphia  in  small  doses  may 
be  combined  with  the  atropine  when  necessary. 
Morphine  and  sitz  baths  will  give  relief  in  almost 
all  cases  of  retention  of  urine  unless  there  is  much 


114    GONORRHOEA  &  ITS  COMPLICATIONS 

swelling  of  the  prostate,  when  the  passage  of  a  small- 
sized  soft  catheter  may  be  necessary. 

The  terminal  haematuria  seldom  requires  special  treat- 
ment, but,  if  severe  and  interference  essential,  it  can  be 
controlled  by  instillations  through  a  soft  catheter  of 
adrenalin  1  :  1000  and  cocaine  2  per  cent. 

Seminal  emissions,  which  are  so  frequently  both 
injurious  and  distressing  in  this  disease,  are  combated 
by  camphor,  potassium  bromide,  heroin,  or  morphia. 

In  cases  of  moderate  severity,  or  when  the  intensity 
of  the  symptoms  has  been  relieved,  local  treatment 
can  be  undertaken,  and  the  only  method  which  can 
be  recommended  is  the  Janet  lavage  with  weak 
permanganate  solutions.  The  lavation  has  to  be 
repeated  every  twelve  hours  until  sufficient  improve- 
ment, as  shown  by  suppression  of  the  discharge  and 
disappearance  of  the  gonococcus,  has  been  obtained  to 
allow  of  greater  laxity,  when  twenty-four,  thirty-six, 
and  forty-eight  hour  intervals  are  progressively  at- 
tained. The  constant  use  of  the  atropine  supposi- 
tories enables  the  treatment  to  be  continued  even  in 
the  presence  of  subacute  prostatitis. 

The  development  of  an  acute  posterior  urethritis 
during  the  course  of  an  anterior  urethritis  which  is 
being  treated  with  lavation  is  impossible  if  the  treat- 
ment is  being  carried  out  with  proper  regard  to  intervals 
and  concentrations  ;  but,  in  the  event  of  such  an 
extension,  the  bladder  fillings  need  not  in  ordinary 
cases  be  discontinued.  Probably  what  would  be 
required  would  be  more  frequent  lavage,  say  every 
twelve  hours. 

Prostatic  massage  is  reserved  until  the  subacute 
stage,  when  it  is  certainly  helpful  to  express  the 
contents  of  the  ducts,  which  are  then  open  to  the 
action  of  the  subsequent  antiseptic  wash. 


ACUTE   GONOCOCCAL    URETHRITIS     115 

The  treatment  of  acute  posterior  urethritis  by  instil- 
lations through  the  Diday,  Ultzmann,  or  Guyon 
canulas  or  catheters  has  been,  and  still  is,  practised 
to  a  limited  extent.  Instillation  into  the  posterior 
urethra  of  silver  nitrate  or  of  the  organic  silver  solu- 
tions has  a  certain  justification  in  subacute  and 
chronic  conditions  ;  but  it  is  a  procedure  which  can- 
not be  practised  with  sufficient  thoroughness  and 
frequency  in  the  posterior  urethra  to  warrant  its 
consideration  as  a  means  of  treating  acute  posterior 
urethritis. 


CHAPTER  VI 

CHRONIC   GONOCOCCAL  URETHRITIS 

By  the  phrase  "  chronic  gonococcal  urethritis  "  is 
meant  a  chronic  inflammation  of  certain  portions  of 
the  urethra  due  to  the  continued  presence  of  the 
gonococcus  after  complete  (though  temporary)  toler- 
ance is  displayed  by  the  major  part  of  the  urethral 
mucosa  and  a  modified  tolerance  by  the  affected 
areas  for  the  particular  strain  of  organism  con- 
cerned. The  tolerance  is  only  relative  and  is  labile — 
that  is  to  say,  an  acute  inflammation  may  follow  ex- 
posure to  a  fresh  infection  and  an  exacerbation  may 
result  from  alcohoHc  and  sexual  excesses,  vaccine 
injections  in  improper  doses,  and  other  causes  which 
affect  the  acquired  immunity  in  ways  which  at 
present  can  only  be  conjectured. 

It  has  already  been  pointed  out  that  a  certain 
amount  of  immunity  is  acquired  by  the  formation  of 
antibodies  in  the  blood  stream,  that  the  power  of 
this  immunity  varies  in  different  individuals,  and 
that  it  is  short-lived.  It  is  probable  that  in  any  given 
case  it  appUes  only  or  principaUy  to  one  of  the  several 
strains  of  gonococci  which  exist. 

In  addition  to  this  general  immunity  a  local  re- 
sistance is  developed,  mainly  by  a  metaplasia  of  the 
urethral  epithelium,  the  cylindrical  cells  becoming 
replaced  by  cells  of  the  squamous  variety.  The 
epithelial  lining  of  the  glands,   however,   does   not 

116 


CHRONIC   GONOCOCCAL   URETHRITIS    117 

participate  so  early  or  so  completely  in  this  change 
into  resistant  tissue,  and  it  is  therefore  for  the  most 
part  in  the  glands  that  we  find  the  sites  of  chronic 
infection. 

These  alterations  in  the  medium  ultimately  affect 
the  virulence  of  the  gonococci,  and  transplanting  to  a 
fresh  soil  is  required  before  the  organism  regains  its  viru- 
lent character.  A  condition  nearly  approaching  equili- 
brium thus  becomes  established  between  the  gono- 
cocci  and  the  tissues,  and  as  a  result  all  evidence  of 
the  activity  of  the  organism,  so  far  as  acute  inflam- 
matory reaction  is  concerned,  is  wanting. 

Post-gonorrhoeal  conditions,  whether  due  to  organ- 
isms following  in  the  train  of  the  gonococcus  or  to 
anatomical  lesions  resulting  from  the  pathological 
processes  incited  by  the  gonococcus,  must  be  strictly 
differentiated  from  chronic  gonococcal  urethritis  in 
which  the  gonococcus  is  still  present. 

It  is  necessary  to  distinguish  with  as  great  an 
amount  of  accuracy  as  it  is  possible  to  attain  between 
chronic  gonococcal  and  post-gonorrhoeal  lesions.  In 
the  one  case,  the  patient  is  liable  to  fresh  outbreaks 
of  gonococcal  activity  in  any  of  its  possible  directions, 
and  what  is  of  even  more  consequence  he  is  still 
capable  of  infecting  others,  while  the  sufferer  from 
post-gonorrhoeal  conditions  who  is  rid  of  the  gonococ- 
cus is  at  least  free  from  these  serious  risks. 

Chronic  gonorrhoea  in  men  is  more  consistently 
infective  than  is  the  same  disease  in  women,  because 
at  each  coitus  the  mixed  secretion  of  all  the  glands 
of  the  male  tract,  including  those  harbouring  the 
gonococcus,  is  thrown  into  the  vagina,  while  only 
a  fractional  part  of  the  female  secretions  gains  en- 
trance to  the  fossa  navicularis. 

The    more    exact    methods    of    demonstrating   the 


118    GONORRHCEA  &  ITS  COMPLICATIONS 

presence  of  the  gonococcus  now  available  enable  the 
diagnosis  to  be  made  with  a  sufficient  degree  of 
assurance  for  practical  purposes,  and  both  from  the 
pathological  and  clinical  points  of  view  the  classifica- 
tion of  chronic  affections  of  the  urethra  resulting 
from  an  acute  gonorrhoea  falls  naturally  into  gonococ- 
cal and  post-gonorrhoeal,  the  latter  assuming  the 
absence  of  the  gonococcus. 

It  is  not  possible  to  state  in  terms  of  time  limits 
when  a  gonorrhoea  can  be  designated  as  chronic.  An 
acute  gonorrhoea  is  usually  understood  to  run  its 
course  in  six  or  eight  weeks,  but  in  certain  instances 
this  period  is  exceeded  either  from  improper  treatment 
or  special  susceptibility  on  the  part  of  the  patient, 
due  perhaps  to  concurrent  tuberculosis  or  syphilis, 
or  to  a  particular  delicacy  of  his  mucous  membranes. 
Such  cases  should  be  called  "  protracted  gonorrhoea." 
Again,  some  cases  show  a  definite  tendency  to  relapse, 
an  acute  exacerbation  following  before  the  termina- 
tion of  the  declining  stage ;  these  are  properly 
alluded  to  as  "  relapsing "  cases.  Finally,  the 
occurrence  of  complications  such  as  prostatitis  or 
epididymitis  may  prolong  the  course,  and  then  the 
term  "  complicated  gonorrhoea  "  is  applicable. 

Excluding  such  cases  as  the  above,  when  a  patient 
remains  uncured  after  ample  time  has  been  allowed 
for  the  fulfilment  of  the  declining  stage,  the  term 
"  chronic  "  is  justifiable. 

Among  the  conditions  which  favour  the  issue  of 
chronicity  are — 

(1)  Improper  treatment  or  conduct. — The  absence  of 
efficient  treatment  is  the  most  frequent  cause  of 
cases  becoming  chronic,  and  next  in  importance  is  the 
failure  of  the  patient  to  follow  the  rules  of  conduct 
laid  down  for  his  guidance,  especially  with  regard  to 


CHRONIC   GONOCOCCAL   URETHRITIS    119 

abstinence  from  alcohol  and  rest  of  the  sexual 
functions.  Treatment  which  is  too  energetic  and 
maintains  a  state  of  urethral  irritation  is  also  re- 
sponsible in  a  few  instances. 

(2)  A  debilitated  state  of  the  patient's  health,  such 
as  may  be  associated  with  tuberculosis,  syphihs,  and 
many  other  diseases,  may  indefinitely  prolong  the 
course  of  a  gonorrhoea. 

(3)  Mucous  membrane  peculiarities. — Some  in- 
dividuals exhibit  a  particular  tendency  to  chronic 
catarrhal  affections. 

(4)  Anatomical  abnormalities. — Para-urethral  pas- 
sages, large  lacunae,  long  or  dilated  ducts  may  be 
the  seats  of  a  long-continued  infection.  A  narrow 
meatus,  while  a  protection  against  infection,  is  an 
agent  in  the  development  of  chronicity  by  inter- 
fering with  active  treatment  and  by  retarding  drain- 
age in  the  acute  stage. 

(5)  Many  cases  can  only  be  accounted  for  on  the 
somewhat  indefinite  ground  of  failure  of  the  im- 
munising mechanism. 

The  symptoms  of  chronic  urethritis  are  :  the  appear- 
ance at  the  meatus  of  a  small  amount  of  muco- 
purulent discharge,  and  the  presence  of  flakes  and 
threads  in  the  first  urine  glass.  The  patient  seldom 
makes  any  complaint  of  discomfort  unless  the  posterior 
urethra  is  deeply  involved.  The  secretion  is  found  in 
most  abundance  before  urination  in  the  morning,  ow- 
ing partly  to  the  long  interval  between  the  acts  of 
micturition  and  partly  to  a  slight  increase  in  the 
morbid  process  in  the  night  time.  Drying  of  the 
secretion  at  the  meatus  may  seal  the  lips,  behind 
which  the  drop  of  muco-pus  is  found.  The  absence 
of  this  secretion  does  not  negative  the  possibility  of 
the  gonococcus  being  present,  but  it  is  usually  the 


120    GOXORRHCEA  6c  ITS  COMPLICATIONS 

continuance   of  this   "  morning   drop  "   which  sends 
the  patient  to  the  surgeon  for  treatment. 

AATien  the  posterior  urethra  is  involved  there  may 
or  may  not  be  symptoms  of  interference  with  the 
sexual  or  urinary  functions.  Disease  of  the  collicu- 
lusseminalis  is  especially  prone  to  produce  these 
disturbances,  but  the  nervous  constitution  of  the 
individual  is  perhaps  the  most  active  factor.  It  re- 
quires the  exercise  of  considerable  judgment  as  well 
as  careful  urethroscopic  and  bacteriological  control 
to  determine  in  which  cases  to  continue  a  prolonged 
course  of  local  treatment  on  account  of  the  risk  of 
pandering  to  a  sexual  neurasthenia ;  but  on  the 
other  hand,  it  is  remarkable  what  excellent  results 
can  be  obtained  in  some  of  these  cases  by  the  in- 
stitution of  a  course  of  appropriate  treatment  after 
an  accurate  and  complete  diagnosis  has  been  made. 
The  symptoms  complained  of  include  discomfort  and 
straining  at  the  conclusion  of  urination,  emissions, 
leakage  of  j^rostatic,  or  on  rare  occasions  spermatic 
secretion  especially  when  at  stool ;  pain  referred  to 
the  end  of  the  penis,  the  testicles,  the  perineum,  the 
back,  the  region  of  the  bladder  and  spermatic  cords 
and  down  the  thighs,  and  also  pain  on  erection  and 
ejaculation.  Patients  afflicted  with  these  symptoms 
are  not  far  removed  from  neurasthenia. 

The  diagnosis  depends  on  finding  the  gonococcus 
in  smears  or  cultures.  A  chronic  catarrhal  state  of 
the  urethra  is  of  fairly  common  occurrence.  Where 
series  of  observations  have  been  recorded  in  medical 
clinics,  the  percentages  in  which  urinary  filaments 
wxre  noted  have  varied  from  30  per  cent  to  50  per 
cent.  These  figures  have  been  extracted  from 
German  sources,  and  thc}^  exceed  the  experience  in 
this  country ;    but  the  important  question  is,  what 


CHRONIC   GONOCOCCAL   URETHRITIS    121 

proportion  of  cases  of  chronic  urethritis  harbours 
the  gonococcus  ?  Scholtz  gives  as  a  result  of  his 
careful  investigations  10  per  cent  as  the  approximate 
number.  Wliile  unable  to  accept  Scholtz's  estimate 
of  the  prevalence  of  chronic  urethritis,  I  believe  he 
considerably  understates  the  proportion  of  cases  of 
chronic  urethritis  following  gonorrhoea  in  which  the 
gonococcus  can  still  be  found.  The  vital  point  in  the 
search  for  the  gonococcus  in  chronic  conditions  is 
the  method  of  collecting  the  material.  As  this  is  a 
question  of  much  importance  it  will  be  considered  in 
detail,  although  this  will  entail  some  repetition  of 
matter  already  discussed. 

In  the  first  place,  the  secretion  collected  within  the 
meatus  in  the  morning,  or  at  least  after  a  long  in- 
terval since  the  last  urination,  should  be  removed  by 
the  insertion  beyond  the  fossa  navicularis  of  a  sterile 
wool-wrapped  probe  of  suitable  calibre.^  The  secre- 
tion is  smeared  on  to  a  couple  of  clean  glass  slides 
which  are  stained  by  Gram's  method  and  examined 
systematically  over  their  whole  surface  until  typical 
gonococci  are  found  or  until  one  is  satisfied  of  their 
absence.  The  other  organisms  present  should  be 
identified  so  far  as  this  is  possible  and  their  relative 
numbers  noted.  Where  adventitious  bacteria  are 
present  in  such  quantities  as  to  obscure  the  gonococci, 
they  may  be  reduced  by  injections  of  weak perchloride 
solution  (1  :  10,000-1  :  20,000)  on  a  few  consecutive 
days,  when  the  field  will  be  more  easily  scanned  and 

^  One  of  the  many  excellent  suggestions  of  Sister  P'risby  of  the  Glasgow 
Lock  Hospital  is  to  enclose  the  wool-covered  probes  in  glass  tubing  and  to 
plug  the  tube  with  wool  before  sterilising.  This  overcomes  the  tendency  of 
the  wool  wrapping  to  become  loosened  in  the  sterilising  process,  and  is  a 
safe  method  of  keeping  the  probes  sterile  until  wanted.  For  this  pur- 
pose straight  probes  are  required^  but  the  handle  can  be  bent  to  an  angle 
when  in  use  if  desired. 


122    GONORRHCEA  &  ITS  COMPLICATIONS 

the  gonococcus  differentiated.  If  these  smears  reveal 
no  gonococci,  another  specimen  should  be  obtained 
direct  from  the  surface  of  any  infiltrated  area  seen 
through  the  urethroscope,  using  either  the  cotton- 
covered  probe  or  a  spoon  to  collect  the  secretion. 

In  the  event  of  the  search  for  the  gonococcus  being 
negative,  it  is  necessary  to  proceed  to  some  method 
of  irritation  in  order  to  stimulate  any  latent  organisms 
into  renewed  activity.  The  hypersemia  and  oedema 
which  follow  an  irritating  application  to  the  urethra 
re-establish  the  conditions  suitable  for  a  temporary 
rejuvenescence  of  the  gonococcus  colonies.  The 
slight  exacerbations  induced  by  the  provocative 
tests  soon  disappear  under  appropriate  treatment. 

The  processes  available  for  this  purpose  are — 

1.  The  passage  of  a  dilating  sound  and  its  reten- 

tion in  the  urethra  for  a  few  minutes. 

2.  Massage    with    the    button-tipped    probe    (ap- 

plicable to  the  anterior  urethra  only). 

3.  The  urethral  injection  of  nitrate  of  silver  solu- 

tion (1  gr.  to  the  ounce). 

4.  The  hypodermic  injection  of   a   small   dose   of 

gonococcus  vaccine  (5-20  millions).  Coinci- 
dent with  the  "  negative  phase "  renewed 
gonococcal  activity  is  noticeable. 

5.  Allowing   the    patient   to   partake    of  alcoholic 

drinks  or  condiments  such  as  pickles  in  suffi- 
cient quantity. 
Massage  with  an  acorn  or  button  tipped  probe  is 
performed  by  extending  the  penis  on  the  abdomen 
after  inserting  the  probe  as  far  as  the  bulb  and  then 
exerting  some  pressure  on  the  penis  with  the  left 
hand,  while  the  right  conducts  the  movements  of 
the  probe.  In  this  way,  the  contents  of  glands  and 
lacunae   are   extracted,    and   being   collected   on   the 


CHRONIC   GONOCOCCAL   URETHRITIS    123 

shoulder  of  the  probe  can  be  used  for  microscopical 
examination.  The  largest  probe  which  will  pass  the 
meatus  should  be  chosen,  and  of  course  no  lubricant 
should  be  used.  Infiltrations  which  impinge  on  the 
urethral  lumen  can  be  diagnosed  by  the  use  of  these 
probes. 

On  the  morning  of  the  day  following  any  of  the 
above  measures  the  secretion  is  examined  as  before, 
when,  if  the  organism  is  still  present  in  the  urethra, 
it  will  almost  surely  be  found  by  an  experienced 
examiner. 

For  the  posterior  urethra  the  most  suitable  local 
interference  is  the  injection  of  silver  nitrate  through 
the  Ultzmann  syringe.  The  passage  of  a  sound,  while 
effective,  is  not  without  risk  of  exciting  an  epididy- 
mitis, though  this  can  be  minimised  by  atropinising 
the  patient.  The  posterior  secretions  are  obtained 
by  rectal  massage  and  expression  after  the  anterior 
urethra  has  been  washed  out.  Secretion  can  also 
be  obtained  direct  from  the  mucosa  of  the  posterior 
urethra  by  the  use  of  the  urethroscope. 

Cultivation  of  the  gonococcus  should  be  attempted 
in  each  case,  not  only  because  success  corroborates 
a  positive  microscopical  finding,  but  also  for  the 
reason  that  in  an  odd  case  when  the  smear  examina- 
tion has  been  fruitless  the  tube  may  show  some 
colonies. 

Specimens  of  flakes  and  threads  may  be  fished  from 
the  urine  or  urethral  Avashings  and  examined  micro- 
scopically for  the  gonococcus,  but  as  a  rule  little 
evidence  of  any  diagnostic  value  can  be  got  from 
them.  They  will  be  found  to  consist  of  mucoid 
material,  epithelial  cells,  leucocytes,  and  usually  some 
micro-organisms.  The  presence  of  a  number  of  pus 
cells  is  suggestive  of  gonococcal  urethritis. 


124    GONORRHCEA  &  ITS  COMPLICATIONS 

It  is  necessary  to  inform  ourselves  of  the  locality 
from  which  these  filaments  have  been  derived — to 
know,  in  fact,  whether  we  are  dealing  with  a  chronic 
anterior  or  with  a  chronic  posterior  urethritis,  or 
both. 

The  ordinary  separate  glass  test  is  of  no  assistance 
in  the  elucidation  of  this  question.  The  secretion 
being  scanty  and  tenacious  adheres  to  the  neighbour- 
hood in  which  it  is  formed.  It  does  not  therefore  reach 
the  bladder  and  become  mixed  throughout  the  urine, 
but  is  washed  out  from  the  surface  of  the  whole 
canal  with  the  first  gush  of  urine,  and  the  formed 
fragments  are  found  for  the  most  part  in  the  first 
glass  irrespective  of  their  place  of  origin.  Syringing 
out  the  anterior  urethra  with  a  colourless  solution, 
e.g.,  boric  acid,  will  remove  the  contents  of  the 
anterior  section  of  the  canal.  These  washings  are 
collected  in  urine  glasses  and  inspected  for  the 
presence  of  filaments.  The  first  portion  of  the 
urine  will  now  contain  specimens  from  the  posterior 
urethra  only. 

Another  method  of  differentiating  is  to  distend  the 
anterior  urethra  with  a  weak  solution  of  methylene 
blue.  All  the  shreds  from  the  anterior  urethra  in  the 
urine  passed  thereafter  are  stained  blue,  whilst  those 
from  the  posterior  urethra  are  unstained  provided 
none  of  the  stain  has  penetrated  beyond  the  com- 
pressor urethrse.  The  use  of  a  cold  solution  of  the 
dye  which  excites  a  strong  contraction  of  the  sphincter 
and  the  avoidance  of  over-distension  will,  in  the  great 
majority  of  cases,  ensure  anterior  staining  only. 
Filaments  from  the  posterior  urethra  may  arise  from 
a  prostatitis  rather  than  a  urethritis.  Only  by  the 
urethroscope  can  these  conditions  be  differentiated 
with  any  approach  to  accuracy. 


CHRONIC   GONOCOCCAL   URETHRITIS    125 

The  size,  shape,  and  syeciiic  gravity  of  the  urinanj 
filaments,  while  they  afford  Uttle  trustworthy  evidence 
of  the  locahty  affected,  may  be  considered  suggestive. 
Long,  Hght  mucous  threads,  which  float  near  the 
surface  and  take  some  time  to  sink  to  the  bottom  of 
the  glass,  are  possibly  derived  from  the  urethral 
mucous  membrane  and  indicate  a  superficial  catarrh. 
Wiereas  the  short,  dense,  and  sometimes  comma- 
shaped  fragments  point  to  glandular  involvement. 
These  heavier  shreds  when  washed  from  the  anterior 
urethra  have  probably  been  expelled  from  the  ducts 
of  Littre's  glands  ;  when  they  are  derived  from  the 
posterior  urethra  they  probably  originate  in  the 
prostatic  tubules.  But  it  must  be  remembered  that 
it  is  impossible  to  base  a  diagnosis  on  these  appear- 
ances. 

On  a  rare  occasion  a  complete  cast  of  the  prostatic 
utricle  or  of  one  of  the  common  seminal  ducts  or 
even  of  a  seminal  vesicle  is  expelled.  This  is  most 
likely  to  occur  subsequent  to  instrumental  dilatation 
of  the  posterior  urethra  and  lavage  with  nitrate  of 
silver  solution,  the  cast  being  found  floating  near  the 
surface  of  the  expelled  solution. 

The  phosphaturia  of  chronic  urethritis. — Phospha- 
turia  is  frequently  observed  especially  in  nervous, 
neurasthenic,  or  melancholic  patients.  It  is  asso- 
ciated with  an  increase  in  the  alkaline  content  of  the 
urine,  and  is  due  not  necessarily  to  any  additional 
phosphatic  excretion,  but  to  the  production  of  the  in- 
soluble basic  phosphates  of  calcium  and  magnesium 
in  place  of  the  soluble  acid  phosphates. 

No  convincing  explanation  of  this  change  has  as 
yet  been  advanced.  It  has  been  ascribed  to  deranged 
kidney  function  of  a  reflex  nervous  nature,  to  exces- 
sive   employment    of    acid    in    gastric    digestion,    to 


126    GONORRHCEA  &  ITS   COMPLICATIONS 

vegetarian  diet,  or  to  the  addition  to  the  urine  of 
alkahne  secretions  from  the  genital  glands. 

As  it  is  not  a  feature  of  chronic  gonorrhoea  in 
women,  two  of  the  above  hypotheses  may  be  rejected 
as  exclusive  causes,  namely,  those  referring  to  the 
digestion  and  the  diet.  Many  American  authorities 
favour  the  view  that  leakage  of  the  secretion  of  the 
seminal  vesicles  into  the  posterior  urethra  is  the 
responsible  factor. 


CHAPTER   VII 

THE   TREATMENT  OF   CHRONIC   GONOCOCCAL 
URETHRITIS 

In-  the  treatment  of  chronic  gonococcal  lesions  there 
are  two  main  indications  to  be  followed — {a)  the 
destruction  of  the  deeply-seated  gonococci,  and  {b) 
the  restitutio  ad  integrum  of  the  diseased  tissues. 
The  former  must  be  complete ;  the  latter,  while  not 
realisable  in  its  entirety,  can  in  the  great  majority  of 
cases  be  imitated  with  sufficient  faithfulness  as  to 
be  clinically  satisfactory.  These  results  can  seldom 
be  attained  by  any  individual  remedial  measure.  A 
combination  of  therapeutic  agents  is  requisite  in 
most  cases,  but  it  will  seldom  happen  that  any  case, 
however  inveterate,  will  fail  to  yield  to  patient  treat- 
ment which  is  governed  by  a  complete  and  definite 
diagnosis.  Chronic  infection  of  para-urethral  passages, 
Cowper's  glands,  the  prostate,  seminal  vesicles,  and 
epididymes  must  be  looked  for  and,  if  found,  treated 
according  to  the  rules  which  will  be  found  discussed 
in  other  chapters. 

The  methods  by  which  chronic  gonorrhoea  can  be 
attacked  include — 

1.  Antiseptic  irrigation,  lavation,  and  injection. 

2.  Dilatation. 

3.  Electrolysis. 

4.  Cauterization. 

5.  Incision. 

6.  Curetting. 

127 


128    GONORRHCEA  &  ITS  COMPLICATIONS 

7.  Instillation. 

8.  Application  of  heat. 

9.  Ionization. 

10.  Medicated  bougies,  ointments,  etc. 

11.  Vaccine. 

Of  the  methods  tabulated  above,  the  first  two,  lava- 
tion  and  dilatation,  have  a  very  wide  appHcation,  and 
are  frequently  used  in  conjunction.  The  next  four 
— electrolysis,  cauterization,  incision,  and  curetting — 
are  practised  in  particular  conditions  which  are 
diagnosed  and  treated  through  the  urethroscope. 

Lavation,  irrigation,  and  injections. — Urethro-vesical 
lavage  is  indicated  when  discharge  is  present  in  any 
quantity,  in  which  case  a  course  of  this  treatment  is 
preliminary  to  any  other  local  interference.  The 
amount  of  discharge  can  always  be  estimated  most 
satisfactorily  by  a  scrutiny  of  the  urine  which  has 
been  retained  for  at  least  three  hours.  The  finding 
of  pus  in  suspension  negatives  the  employment  of 
any  more  active  measures  until  treatment  has  cleared 
the  urine.  The  solutions  of  most  value  are  perman- 
ganate of  potash,  1  :  6000-1  :  2000  ;  nitrate  of  sil- 
ver, 1  :  4000-1  :  1000  ;  and  oxycyanide  of  mercury, 
1  :  10,000-1  :  4000.  The  method  has  been  fully 
described  in  treating  of  acute  urethritis.  Irrigation 
is  only  adopted  when  using  an  irrigating  dilator. 

Astringent  injections  are  used  to  hasten  a  pro- 
longed declining  stage  or  to  supplement  the  lavage 
treatment.  They  assist  in  suppressing  mucous  and 
sero-mucous  discharge.  The  sulphate  of  zinc 
(1  :  1000-1  :  500)  is  the  most  serviceable  astringent. 
Sulphate  of  copper  (1  :  4000-1  :  1000)  is  more  irri- 
tating, but  it  is  also  useful,  and  may  be  combined 
with  the  zinc  sulphate. 

In  calculating  the  strength  of  a  solution  for  use 


CHRONIC   GONOCOCCAL   URETHRITIS    129 

as  an  injection,  it  should  be  remembered  that  the 
longer  the  solution  is  retained  in  the  urethra  and 
the  greater  the  quantity  of  fluid  used  the  Aveaker 
must  the  concentration  be.  Instead  of  holding  one 
syringeful  in  the  urethra  for  the  stipulated  time,  it  is 
preferable  to  adopt  the  weak  solutions  suggested 
above,  using  several  fillings  of  the  syringe  one  after 
the  other,  keeping  each  in  the  canal  for  one  minute. 

It  is  seldom  that  the  mere  use  of  astringent  in- 
jections will  cure  a  case  of  chronic  gonococcal  ure- 
thritis, and  if  circumstances  necessitate  a  trial  of 
this,  the  simplest  form  of  treatment,  it  must  be 
superseded  by  more  effective  measures  if  no  benefit 
results  within  a  week  or  two.  The  longer  resolution 
is  delayed  the  more  permanent  are  the  pathological 
deposits  which  are  in  progress  of  formation,  and  the 
longer  is  the  course  of  treatment  which  will  eventually 
be  required.  The  popularity  of  this  method  is  not  due 
to  its  intrinsic  value,  but  to  less  meritorious  reasons. 

Dilatation  is  the  most  generally  useful  means  we 
have  at  present  at  our  command  for  inciting  the 
retrogressive  histological  changes  which  tend  towards 
restitution.  Urethro-vesical  lavage  by  the  Janet 
method  acts  to  some  extent  as  a  dilator,  and  doubt- 
less a  proportion  of  the  beneficial  effect  of  this  mode 
of  treatment  is  due  to  the  action  of  the  hydraulic 
pressure  on  the  infiltrations.  There  are  three  different 
forms  of  instrument  used  for  this  purpose — {a)  flexible 
bougies,  the  original  predecessor  of  which  was  a  fine 
wax  candle,  hence  the  name  ;  (h)  metal  sounds  made 
of  plated  steel  or  copper  ;  (c)  metal  dilators  capable 
of  mechanical  expansion  and  reclosure  within  the 
urethra. 

In  some  schools  all  solid  dilating  instruments  are 
called  bougies,   the  word  sound  being  restricted  to 

WATSOX.  ■ — K 


130    GOXORRHCEA  &  ITS  COMPLICATIONS 

stone  searchers.  This  erroneous  interpretation  prob- 
ably arises  from  the  fact  that  the  stone  searcher 
eUcits  a  "  sound  "  on  being  tapped  against  a  calculus, 
but  this  has  no  connection  with  the  derivation  of  the 
word. 

The  clinical  value  of  dilatation  by  sounds  has  long 
been  recognised,  but  Oberlaender  and  Kollmann  have 
greatly  enlarged  its  usefulness  and  scope.  Kollmann 
has  introduced  a  series  of  dilating  instruments 
specially  designed  to  suit  the  anatomical  contour  of 
the  different  divisions  of  the  urethra.  These  ex- 
panding   dilators    enable    treatment    to    be    carried 


Fig.  30. 
Glutton's  steel  sounds. 


beyond  the  point  attainable  with  the  largest  sound 
capable  of  passing  the  meatus. 

Dilatation,  in  addition  to  stretching  constricted 
parts  of  the  canal,  excites  changes  in  the  infiltrated 
area  which  have  a  tendency  the  opposite  of  that 
induced  by  the  slow  continuous  irritation  of  a  chronic 
gonococcal  infection  ;  so  that  by  a  properly  timed 
and  graduated  course  of  dilatation  the  infiltrations 
become  absorbed,  closed  ducts  are  opened,  and 
glands  and  lacunae  emptied  of  their  contents.  It  is 
essential,  therefore,  that  each  dilatation  should  be 
followed  or  accompanied  by  urethro-vesical  irrigation 


CHRONIC    GONOCOCCAL   URETHRITIS    131 

to  remove  the  expressed  infective  material.  Instru- 
mental dilatation  affects  not  only  infiltrations  which 
impinge  on  the  urethral  lumen,  but  it  also  acts 
beneficially  on  the  minor  degrees  and  forms  of  infiltra- 
tion. 

The  first  step,  however,  is  to  determine  the  presence 
or  absence  of  obstruction  by  the  use  of  an  acorn- 


Fk;.  31. 
Acorn  and  olivary  tip  bougies. 

tipped  flexible  bougie.  The  results  of  this  investiga- 
tion will  indicate  the  nature  and  size  of  the  instru- 
ment next  to  be  inserted. 

The  best  instruments  for  this  mode  of  treatment 
are  metal  sounds  (Figs.  30  and  35)  ;  but  when  cicatri- 
cial changes  are  so  far  advanced  in  an  infiltration 
that  a  stricture  has  resulted,  it  may  be  necessary  in 
the  first  place  to  employ  flexible  bougies  (Fig.  31) 
until  the  canal  has  been  widened  sufficiently  to  allow 


Fig.  33. 
Filiform  bougies. 

of  the  passage  of  a  sound  without  the  use  of  any 
force.  It  is  not  advisable  to  attempt  the  passage  of 
a  metal  instrument  smaller  than  No.  10  or  perhaps 
even  No.  12  Charriere. 

The  utmost  gentleness  must  be  exercised  in  prac- 
tising the  insertion  of  instruments.    The  formation  of 


132    GONORRHCEA  &  ITS  COMPLICATIONS 

false  passages  or  the  production  of  traumatism  of  the 
healthy  urethral  mucosa  has  to  be  guarded  against. 
It  must  not  be  forgotten  that  the  urethral  mucosa  is 
an  exceedingly  sensitive  structure,  comparable  in 
this  respect  to  the  conjunctiva,  and  therefore  re- 
quiring most  delicate  handling.  The  instrument 
should  be  inserted  gently  and  tactfully  past  any 
obstruction.  It  must  lie  lightly  in  the  hand,  in  order 
that  the  fullest  delicacy  of  the  sense  of  touch  may  be 
brought  into  play.  Once  the  tip  of  the  sound  is 
successfully  past  the  point  where  the  infiltration  is 
known  to  lie,  the  tapering  shaft  is  lightly  and  steadily 
slipped  through  the  infiltration.  The  healthy  portion 
of  the  urethra  readily  distends,  but  the  inelastic 
diseased  area  is  gradually  broken  up.     The  aim  is  to 


Fig.  33. 
Torpedo  sound  for  penile  infiltrations. 

produce  a  multitude  of  minute  traumatic  lesions  in 
the  infiltration,  as  a  result  of  which,  processes  of 
absorption  are  initiated,  and  this  effect  is  achieved 
by  slow,  steady,  and  gentle  dilatation.  The  weight 
of  the  sound  is  almost  sufficient  in  itself,  and  cer- 
tainly neither  pain  nor  bleeding  should  be  produced. 
Macroscopic  lesions  only  delay  the  progress  of  the 
cure. 

In  order  to  ensure  the  minimal  character  of  the 
lesions  in  the  infiltrations,  it  is  necessary  to  proceed 
by  very  small  gradations  from  the  one  to  the  next 
sound.  For  this  reason  sounds  conforming  to  the 
English  scale  are  unsuitable,  and  even  the  ordinary 
French  Charriere  scale,  which  increases  by  one-third 
of  a  millimetre,  fails  to  meet  all  the  requirements 


CHRONIC   GONOCOCCAL    URETHRITIS    133 

(Fig.    34).      A   new   scale   known   as   the   Guyon   or 
Benique,  in  which  the  number  of  sounds  has  been 


doubled,  is  finding  much  favour  with  urologists.  In 
the  Charriere  set  there  are  thirty  instruments,  three 
to   each   millimetre,   and  therefore  the   diameter   of 


134    GONORRHCEA  &  ITS  COMPLICATIONS 

number  thirty  is  ten  millimetres  and  the  circmnference 
thirty  millimetres.  In  the  Guyon  scale  there  are  six 
to  each  millimetre,  and  number  sixty  is  ten  milli- 
metres thick  and  corresponds  to  number  thirty 
Charriere.  Nothing  is  to  be  gained  by  retaining  the 
old  English  gauge  ;  on  the  contrary,  much  confusion 
would  be  obviated  by  the  general  adoption  of  a 
universal  scale.  It  seems  unfortunate  that  a  system  of 
numbering  different  to  the  Charriere  scale  should  have 
been  suggested.  The  increase  in  the  number  of  in- 
struments for  which  there  is  some  justification  could 


Fig.  35. 
Watson's  dilating  .sound. 

have  been  quite  satisfactorily  dealt  with  by  the 
addition  either  of  a  plus  sign  (  +)  or  -5  to  the  ordinary 
Charriere  number  for  the  intermediary  sizes. 

It  is  a  distinct  advantage  for  the  shaft  of  the 
sound  to  be  reduced  in  size  proximal  to  the  bellied 
dilating  portion  so  as  to  free  the  tension  on  the 
meatus.  This  improvement  was  first  suggested  by 
J.  H.  Nicoll.  It  prevents  the  possibility  of  friction 
at  the  meatus  obscuring  the  actual  urethral  con- 
dition. 

When    sounds    of    the    Guvon    measurements    are 


CHRONIC   GONOCOCCAL    URETHRITIS    135 

employed  three  instruments  may  be  passed  at  each 
visit.  If  Enghsh  or  Charriere  sounds  are  used  only 
two  should  be  tried  at  one  treatment,  beginning  with 
the  largest  size  used  at  the  previous  consultation. 
There  is  little  or  no  advantage  to  be  obtained  by 
leaving  the  sound  in  situ  for  any  length  of  time  ; 
the  longer  it  is  retained  the  firmer  will  be  the  grip  of 
the  urethra  on  the  instrument.  Relaxation  such  as 
is  aimed  at  in  the  continuous  method  of  dilatation 
does  not  inake  its  first  appearance  for  several  hours. 
The  sound  which  is  illustrated  above  (Fig.  35) 
was  made  for  me  by  Messrs.  Down  Bros.    Its  features 


Fig.  36. 
Olivary-tip  bougies. 

are  :  (1)  Each  instrument  has  a  round  ball  point ; 
the  usual  sharper  oval  point  of  a  Lister  sound  tends 
to  become  caught  at  any  obstructing  point,  and, 
even  in  the  healthy  urethra,  the  cul-de-sac  which 
often  exists  at  the  extremity  of  the  bulbous  portion 
of  the  urethra  presents  a  difficulty.  (2)  The  curve  is 
shorter  and  more  acute  than  in  the  common  English 
pattern.  This  facilitates  its  entrance  into  the  pos- 
terior urethra.  (3)  Each  sound  tapers  to  the  extent 
of  four  numbers  of  the  Charriere  scale.  The  expan- 
sion begins  three  centimetres  from  the  ball  tip, 
reaches  its  inaximum  in  other  three  centimetres,  and 
retains   the   maximum   for   six   centimetres,    beyond 


136    GONORRHCEA  &  ITS  COMPLICATIONS 

which  the  diameter  is  gradually  reduced,  leaving  a 
narrow  shaft,  which  is  not  gripped  by  the  meatus. 
When  fully  introduced  into  the  urethra,  the  en- 
larged portion  of  the  sound  lies  in  the  posterior 
urethra  with  only  the  ball  point  and  short  curve  in 
the  bladder.  These  instruments  are  thus  equally 
useful  for  the  anterior  or  posterior  urethra,  but 
straight  sounds  on  similar  principles  are  made  for  the 
anterior  urethra  (Fig.  37).  The  smallest  size  which 
I  use  is  10-14,  and  the  largest  26-30  (Charriere),  the 
set  comprising  sixteen  instruments.  For  strictures 
requiring   smaller   instruments   than    10-14,    flexible 

■•ISc 


Full   Size 


Fig.  37. 
Watson's  straight  anterior  dilating  sound. 

olivary  bougies  should  be  used  until  sufficient  dilata- 
tion has  been  achieved  to  allow  of  the  easy  and 
safe  introduction  of  the  metal  sound. 

Dilatation  may  be  repeated  as  a  rule  every  three 
days,  but  when  a  marked  reaction  follows  a  treatment, 
or  when  bleeding  results  at  the  time,  the  interval  is 
extended.  Bleeding  in  chronic  cases  is  usually  due 
to  a  longitudinal  tear,  and  whenever  this  is  noticed 
dilatation  should  be  stopped  immediately  and  not 
repeated  for  ten  days.  If  the  bleeding  is  trouble- 
some, there  is  no  objection  to  the  injection  of  a  small 
quantity  of  adrenalin.  When,  on  using  a  smaller 
sound  after  an  interval  sufficient  to  allow  of  healing, 
bleeding  recurs,  a  careful  urethroscopic  search  may 
be  made  to  exclude  erosions  or  papillomatous  growths. 

It  has  already  been  remarked  that  dilatation  is 


CHRONIC    GONOCOCCAL    URETHRITIS    137 

always  accompanied  by  flushing  the  urinary  tract. 
This  may  be  accomphshed  by  filhng  the  bladder 
previous  to  the  passage  of  the  sound  and  discharging 
the  contents  after  the  operation  of  dilating,  or  the 
bladder  may  be  both  filled  and  emptied  after  the 
dilatation.  The  solutions  of  most  service  for  the 
former  method  are  1  :  4000  oxycyanide  of  mercury 
and  concentrated  boric  acid.  Oxycyanide  of  mercury 
should  be  avoided  if  the  patient  has  recently  been 
dosed  with  potassium  iodide.  The  iodide  of  mercury 
which  forms  in  the  bladder  in  such  cases  is  very 
irritating  to  the  mucous  membrane  and  produces 
cystitis.  Permanganate  may  be  used  for  lavage  after 
dilatation,  but  it  must  not  be  instilled  into  the  bladder 
before  passing  the  sound  on  account  of  its  con- 
tractile effect  on  the  mucous  membrane,  which  would 
greatly  impede  the  insertion  of  the  instrument. 
Silver  nitrate  (1  :  10,000-1  :  4000)  is  particularly  use- 
ful in  combination  with  dilatation.  A  good  result 
can  often  be  got  from  its  use  when  other  agents  are 
slow  or  ineffective.  In  addition  to  its  astringent  and 
antiseptic  action,  it  excites  a  marked  contraction  of 
the  musculature  of  the  urethra  and  its  adnexa  as  well 
as  of  the  bladder,  and  thus  facilitates  emptying  of 
distended  folhcles  and  ducts.  One  of  the  organic 
silver  compounds  may  be  employed  in  the  same  way. 
Meatotomy. — Section  of  the  meatus  is  sometimes 
necessary  before  dilatation  treatment  can  be  com- 
pleted. In  some  cases  a  close  examination  of  the 
meatus  will  show  the  presence  of  transverse  ad- 
hesions, the  snipping  of  which  will  considerably 
enlarge  the  aperture.  In  other  cases  the  encroach- 
ment is  purely  membranous,  and  this  may  require 
incision  at  both  angles.  As  a  rule,  however,  what  is 
required  is  incision  of  the  lower  angle  of  the  meatus. 


138    GONORRHCEA  &  ITS  COMPLICATIONS 

The  angle  of  the  wound  and  each  side  may  receive  a 
stitch  of  fine  catgut  to  control  bleeding  and  prevent 
reunion. 

Kollmann's  dilators  (Fig.  38)  are  of  great  value 
when  the  sounds  have  reached  the  limit  of  their 
usefulness  and  further  treatment  is  still  required. 
The  meatus,  the  narrowest  part  of  the  canal,  obstructs 
the  admission  of  sounds  of  sufficient  calibre  to  pro- 
duce the  maximum  beneficial  effects  of  dilatation. 
Kollmann's  dilators  are  therefore  designed  so  that 
they  will  pass  an  ordinary  meatus  without  difficulty, 


Fig.  38. 
Kollmann's  dilators. 

and  thereafter  they  can  be  expanded  to  any  desirable 
extent  without  interfering  with  the  width  at  the 
meatus,  and  they  are  again  collapsed  before  with- 
drawal. Various  instruments  are  supplied  suitable 
for  different  regions.  For  the  anterior  urethra  a 
straight  dilator  is  used,  and  for  the  posterior  urethra 
one  with  a  suitable  curve.  It  is  necessary  to  be 
furnished  with  both,  although  the  former  is  more 
frequently  required.  The  form  which  is  applicable 
to  the  entire  urethra  can  very  rarely  be  the  proper 
instrument  to  use.  In  each  case  an  irrigating  attach- 
ment is  an  advantage,  but,  as  mentioned  above, 
permanganate  solution  must  not  be  adopted  as  the 


CHRONIC   GONOCOCCAL    URETHRITIS    139 

cleansing  fluid,  otherwise  difficulty  would  be  ex- 
perienced in  withdrawing  the  instrument,  which  would 
be  found  tightly  gripped  by  the  urethra. 

These  dilators  should  not  be  used  more  frequently 
than  twice  in  one  week.  Four  or  five  day  intervals 
are  preferable.  The  onset  of  bleeding  is  an  indica- 
tion for  at  least  a  fortnight's  rest. 

The  index-dial  attached  to  the  instrument  shows 
the  amount  of  dilatation  which  the  rotation  of  the 
screw-handle  has  achieved.  All  that  has  been  said 
with  reference  to  the  need  for  care  and  gentleness  in 
the  use  of  the  sound  applies  with  equal  force  in  the 
case  of  Kollmann's  dilators.  The  site  of  the  infiltra- 
tion must  be  accurately  located,  the  appropriate 
instrument  chosen,  and  the  increase  in  the  amount 
of  dilatation  attempted  must  be  carefully  controlled, 
never  exceeding  two  or  at  the  most  three  numbers 
above  the  former  application. 

While  the  improvement  in  the  condition  of  the 
parts  as  shown  by  the  decrease  in  the  quantity  of 
gleety  discharge  and  in  the  number  of  urinary  fila- 
ments w^ill  encourage  both  the  patient  and  the  medical 
attendant  to  persevere,  it  is  wise  in  all  cases  to  have 
recourse  periodically  to  urethroscopic  examination 
for  corroboration. 

Three  suppositories  of  atropine  sujphate  (1/75 
grain)  should  be  used  in  connection  with  each  instru- 
mental interference  to  abolish  the  tendency  to  reflex 
peristalsis  along  the  ejaculatory  ducts  and  thus 
eliminate  the  risk  of  exciting  epididymitis.  A  sup- 
pository is  inserted  into  the  rectum  the  night  and 
morning  before  the  dilatation  and  one  the  night 
following.  On  the  same  occasions  10  grains  of  hexa- 
methylenamin  may  be  prescribed. 

Electrolysis,  cauterization,  incision,  and  curetting  are 


140    GONORRHCEA  &  ITS  COMPLICATIONS 

only  possible  under  the  conditions  which  make  ure- 
throscopy justifiable — that  is  to  say,  there  must  be  no 
acute  inflammation,  and  the  urethra  must  be  suffi- 
ciently dilatable  to  admit  the  endoscope  tube  without 
pain  or  haemorrhage. 

Electrolysis  is  the  most  useful  and  thorough  means 
we  possess  for  the  destruction  of  chronically  diseased 
follicles,  crypts,  para-urethral  passages,  etc.,  which 
may  survive  lavage  and  dilatation.  The  amount 
of  tissue  destruction  is  easily  controlled,  and  can  thus 
be  limited  to  pathological  structures.  It  is  unwise  to 
treat  more  than  three  or  four  spots  at  one  sitting,  and 


Fig.  39. 
Electrolysis  needles  and  holder. 

these  should  not  be  close  together,  so  that  in  case  of 
over  -  treatment  the  resulting  cicatrices  would  not 
coalesce.  The  discrete  point  cicatrices  which  follow 
careful  application  of  the  electrolytic  needle  are 
entirely  harinless. 

The  apparatus  which  is  necessary  consists  of  a  special 
holder  and  needle  for  urethroscopic  work  (Fig.  39),  a 
battery  or  accumulator  of  at  least  four  volts  with  a 
crank  collector  or  other  arrangement  for  regulating 
the  strength  of  the  current,  a  milliampere-meter,  and 
flexible  connection  cords.  The  positive  electrode, 
usually  a  zinc  plate  with  a  moistened  sponge  at- 
tached, may  be  strapped  to  the  patient's  thigh   or 


CHRONIC   GONOCOCCAL    URETHRITIS    141 

arm,  while  the  negative  pole  is  connected  with  the 
needle-holder.  A  current  of  three  niilliamperes  should 
not  be  exceeded,  and  the  duration  of  the  exposure 
should  be  limited  to  about  sixty  seconds.  The  point 
of  the  needle  can  be  bent  into  such  form  as  will 
enable  it  to  penetrate  as  far  as  is  desired  into  the 
duct. 

That  the  electrolysis  is  proceeding  satisfactorily, 
after  the  needle  has  been  inserted  the  desired  depth 
into  the  follicle,  is  evidenced  by  the  appearance  of 
minute  bubbles  of  froth  escaping  alongside  the  needle. 
A  little  practice  with  hair  follicles  on  their  own  skin 
is  advisable  for  beginners,  and  will  enable  them  to 
estimate  approximately  the  amount  of  reaction  to  be 
expected  from  currents  of  different  strengths  and 
durations. 

Electrolysis  is  the  cleanUest  and  surest  method  of 
destroying  scattered  foci  of  infection  when  such 
have  been  discovered  through  the  urethroscope. 
There  is  no  difficulty  in  permanently  removing  any 
offending  gland  or  crypt  by  this  means,  and  the 
resulting  scar,  unless  the  treatment  has  been  un- 
necessarily excessive,  is  negligible.  Over-treatment, 
especially  of  a  number  of  closely  aggregated  follicles, 
would,  however,  lead  to  more  or  less  stricture,  and 
this,  of  course,  must  be  avoided.  In  some  cases 
destruction  of  the  gland  is  not  indicated,  and  electro- 
lysis treatment  which  stops  short  of  scar  formation 
might  suffice  to  eliminate  the  gonococci  and  lead  to 
cure. 

Cauterization  may  be  achieved  by  means  of  (a) 
the  electric  cautery,  several  forms  of  which  are  made 
for  urethral  work  ;  (b)  the  application  of  solid  nitrate 
of  silver  fused  on  to  the  end  of  a  urethral  probe  ; 
(c)  touching  with  strong  caustic  solutions. 


142    GONORRH(EA  &  ITS  COMPLICATIONS 

The  galvano- cautery  performs  much  the  same  func- 
tion as  the  electrolytic  needle  in  the  destruction  of 
granulations,  polypi,  and  warts.  Polypi  frequently 
occur  in  the  posterior  urethra  in  the  region  of  the 
verumontanum,  and  once  an  assured  diagnosis  has 
been  made  they  may  be  destroyed  by  the  cautery. 
Warts  seldom  require  the  use  of  the  cautery,  as  they 
can  usually  be  made  to  disappear  by  injections  of 
lactic  acid  (1  in  200)  or  direct  applications  of  a  swab 
of  the  pure  acid.  For  intractable  papillomata,  re- 
course may  be  had  to  the  electric  cautery.  A  special 
battery  is  used  for  cautery  work,  as  a  high  amperage 
combined  Avith  low  voltage  are  requisite.  A  rheostat 
is  attached  to  regulate  the  current,  and  special  cautery 
cords  are  also  needed. 

In  employing  the  cautery  the  urethroscope  is 
tilted  in  such  direction  as  will  bring  the  growth  well 
into  the  end  of  the  tube.  The  field  is  thoroughly 
dried,  the  cold  cautery  is  introduced,  and  the  connec- 
tion made  and  maintained  until  the  base  of  the 
polypus  is  destroyed.  Several  applications  with 
intervening  inspections  may  be  required.  Care  must 
be  taken  not  to  embed  the  cautery  in  the  tissue,  other- 
wise haemorrhage  will  follow  its  withdrawal.  The 
pressure  used  must  therefore  be  of  the  lightest. 

The  disadvantages  of  the  galvano-cautery  are  the 
production  of  smoke  which  obscures  the  view,  the 
liability  to  haemorrhage,  the  danger  of  septic  infection 
of  the  burned  area,  and  the  risk  of  over-treatment 
producing  obstructive  cicatrices. 

Cauterization  by  silver  nitrate  is  only  suitable  for 
small  areas,  and  only-  one  side  of  the  urethra  should 
be  attacked  to  obviate  the  production  of  strictures. 
Longitudinal  scars  may  be  of  little  consequence,  but 
most  unhappy  effects  are  certain  to  follow  if  a  circular 
cicatrix  is  encouraged. 


CHRONIC   GONOCOCCAL    URETHRITIS    143 

Topical  applications  of  strong  solutions  of  silver 
nitrate  (10  per  cent)  serve  most  of  the  purposes  of 
chemical  cauterization.  Solutions  can  be  applied 
on  swabs,  care  being  taken  to  avoid  healthy  mucous 
membrane,  but  greater  precision  is  secured  by  the 
use  of  a  fine  camel-hair  brush  concealed  in  a  narrow 
tube.  When  the  tube  reaches  the  spot  to  be  treated 
the  brush  is  projected  from  its  container  by  means 


Fig.  40. 
Burghard's  urethral  knife,  with  blunt  end. 


of  a  spring.  Tincture  of  iodine  used  in  this  manner 
is  often  of  service.  Salicylic  acid  is  also  used,  es- 
pecially for  keratinized  spots.  In  the  posterior 
urethra,  applications  of  silver  nitrate  solution  or  of 
tincture  of  iodine  by  the  brush  to  a  hypertrophied 
and  congested  verumontanum  are  frequently  of  great 
benefit. 

Solutions  can  also  be  injected  into  the  sinus 
pocularis  or  into  the  gaping  orifice  of  any  diseased 
gland  by  means  of  a  special  canula  to  which  a  small 
syringe  can  be  attached. 


Fig.  41. 
Burghard's  sickle-shaped  urethral  knife. 


Incision  is  indicated  when  any  small  abscess  is 
detected  through  the  urethroscope.  Fibrous  bands 
and  undilatable  strictures  may  also  be  divided  with 
the  help  of  the  urethroscope. 


144    GONORRHCEA  &  ITS  COMPLICATIONS 

Curetting  is  of  most  use  for  granulations  and  small 
growths.  It  may  be  followed  by  the  application  of 
caustic  solutions. 

Endourethral  scissors,  forceps,  punch  and  aspirat- 
ing pipette  are  also  useful  instruments  for  individual 
cases. 

Instillations. — By  instillation  is  meant  the  injection 
of  from  one  to  twenty  drops  of  a  strong  medicament 
into  one  region  of  the  urethra  where  the  disease  is 
localised.  This  method  is  employed  principally  for 
the  prostatic  urethra,  and  either  the  Guyon  or 
Ultzmann  syringe  (Figs.   43  and  44)  may  be  used. 


^ 


PULL    SIZE 


Fig.  42. 
Wyndham  Powell's  urethral  punch. 

Nitrate  of  silver  solution,  2  per  cent  to  5  per  cent,  is 
adopted  more  frequently  than  any  other  for  this 
purpose.  This  procedure  is  now  much  less  frequently 
employed  than  formerly,  being  displaced  by  the 
more  precise  and  less  dangerous  methods  applicable 
through  the  endoscopic  tube.  One  or  two  injections 
of  a  few  drops  of  the  weaker  solution  are,  however, 
quite  justifiable,  and  they  will  be  found  to  act 
beneficially  in  some  cases.  The  class  of  case  for 
which  they  are  suited  is  that  in  which  there  is  a 
superficial  epithelial  catarrh  remaining  indefinitely 
after  the  gonococcal  inflammation  has  subsided  and 
when  infiltrations  are  in  process  of  formation. 

Thermo-therapy .  —  The     observation     that     most 
strains  of  gonococci  are  killed  by  comparatively  low 


CHRONIC    GONOCOCCAL   URETHRITIS    145 

temperatures  (40°  C.  in  six  hours)  led  to  many  at- 
tempts to  utilise  heat  in  the  treatment  of  gonorrhoea. 
The  published  results  so  far  have  been  conflicting. 
While  the  surface  temperature  of  the  urethral  mu- 
cosa can  easily  be  raised,  it  is  difficult  to  have  suffi- 
cient effect  on  the  underlying  vascular  tissues  with 


Fig.  43. 
Guyon's  syringe. 

their  rapidly  circulating  blood  stream.  It  is  con- 
ceivable that  as  a  method  of  aborting  gonorrhoea 
thermal  treatment  might  be  successful,  provided  the 
infection  was  limited  to  the  pendulous  urethra.  A 
ligature  should  be  applied  to  the  root  of  the  penis, 
while  an  electrical  bougie  inserted  into  the  pendulous 
urethra  is  retained  in  position  for  thirty  minutes  at 


Fig.  44. 
Ultzmann's  syringe. 

the  maximum  bearable  temperature  (45°  to  48°  C). 
Whatever  the  final  conclusion  may  be  regarding  the 
practicability  of  the  heat  treatment  for  acute  gonor- 
rhoea, it  is  now  accepted  as  being  of  distinct  value 
in  certain  chronic  conditions,  particularly  infiltra- 
tions and  prostatitis. 

There  are  two  modes  in  which  the  treatment  can 


146    GONORRHCEA  &  ITS  COMPLICATIONS 

be  applied — (a)  hollow  double-channel  sounds  for  the 
cnxulation  of  hot  water,  and  (b)  electrically-heated 
bougies.  The  thermo-penetration  is  more  rapid  and 
complete  with  the  latter  instruments,  but  they  re- 
quire more  care  and  experience  in  their  handling. 
One  hour  of  the  hot-water  circulation  corresponds  to 
a  quarter  of  an  hour  with  the  electric  bougies. 

Hot- water  sounds. — (Fig.  45.)  The  inlet  is  connected 
with  a  reservoir  placed  eighteen  inches  above  the  re- 
cumbent patient,  and  containing  water  at  46°  C.  The 
exit  tube  empties  into  a  bucket.  The  sound  is  passed 
into  the  bladder  and  the  water  allowed  to  circulate.  By 
the  addition  of  hot  water  to  the  irrigator  the  tempera- 


STENMOUSE 


Fig.  45. 
Hot- water  sound. 

ture  is  gradually  raised  to  52°  C,  and  it  is  kept  at  this 
heat  until  the  end  of  the  operation  (thirty  to  sixty 
minutes). 

The  size  of  instrument  used  must  be  one  which  will 
pass  readily,  and  no  cocaine  should  be  employed  to 
obliterate  the  natural  feeling  of  the  urethra  and  abolish 
an  important  safeguard  against  overheating.  In  a  few 
minutes  the  warmth  establishes  a  feeling  of  comfort, 
and  if  the  right  temperature  is  being  used  no  pain 
should  be  complained  of.  The  urethral  mucosa  is 
not,  of  course,  raised  in  temperature  to  an  equality 
with  the  circulating  water.  There  is  probably  a 
difference  of  about  10°  C. 

The  Kohelt  electrically-heated  bougies  are  the  best 
pattern   on  the   market.     Both   flexible    and   metal 


CHRONIC   GONOCOCCAL   URETHRITIS    147 

instruments  can  be  obtained.  The}^  are  heated 
by  the  insertion  in  the  interior  of  the  instrument  of 
a  resistance  coil.  A  control  thermometer  in  the 
circuit  indicates  the  heat  of  the  instrument. 
The  current  is  supphed  by  an  ordinary  accumu- 
lator with  rheostat.  An  automatic  closure  of  the 
current  prevents  too  high  a  temperature  being 
registered. 

Technique. — The  temperature  of  the  lubricated 
bougie  is  raised  to  37°  C,  and  it  is  introduced  into 
the  urethra  with  aseptic  precautions.  The  tempera- 
ture is  gradually  raised  to  50°-55°  C.  Higher  degrees 
are  painful.  Each  bougie  is  retained  in  the  urethra 
for  ten  minutes,  wiien  it  is  withdrawn  and  the  next 
size  inserted.  Three  sizes  are  used  at  each  seance, 
which  therefore  lasts  thirty  minutes. 

The  result  of  this  treatment  is  an  active  hypersemia, 
and  the  appearance  at  the  meatus  alongside  the 
bougie  of  some  sero-mucous  exudation. 

It  is  maintained  by  Scharrf,  Kobelt,  Fulton,  and 
others  that  absorption  of  infiltrations  is  attained 
more  quickly  and  painlessly  by  the  heat  method  than 
by  simple  dilation  with  sounds. 

It  has  been  found  that  Avhen  a  stricture  is  im- 
passable to  the  smallest  bougie,  the  insertion  of  the 
warm  instrument  as  near  as  possible  to  the  stricture 
for  ten  minutes  or  more  will  cause  it  to  dilate  suffi- 
ciently to  enable  a  bougie  to  pass. 

The  treatment  is  repeated  two  or  three  times  a 
week  unless  contra-indicated  by  the  occurrence  of 
bleeding  or  excessive  reaction. 

Ionization. — The  principle  of  "  ionic  medication  " 
has  been  applied  in  chronic  urethral  infection  in  the 
hope  of  reaching  the  tissue-embedded  organisms.  Zinc 
and  silver  have  been  tried.     In  using  the  former,  the 


148    GONORRHCEA  &  ITS  COMPLICATIONS 

urethral  electrode  (Fig.  46)  is  essentially  a  gum-elastic 
catheter  minus  the  bladder  eyelet,  but  with  many 
lateral  perforations  on  its  walls  and  a  central  zinc 
st^det.  The  outer  end  of  the  catheter  should  be  cone- 
shaped  so  as  to  plug  the  urethra,  and  the  end  of  the 
stylet  should  fit  snugly  into  the  catheter  and  close  its 
aperture.  With  the  catheter  in  the  urethra,  sulphate  of 
zinc  solution  (f  per  cent)  is  injected.  The  zinc  stylet 
is  inserted  and  connected  with  the  positive  pole  of  a 
constant  battery. 

The  kathode  is  applied  to  the  patient's  thigh  or 
other  convenient  position,  and  a  current  of  five  milli- 


Fi&.   46. 
Pollmann's  electrode  for  urethra. 


amperes  turned  on  for  five  minutes.  The  effect  in 
most  cases  is  to  excite  a  purulent  discharge  which 
disappears  in  a  few  days,  and  the  condition  is  then 
found  somewhat  improved. 

Better  results  are  reported  by  Luys  with  silver  ions. 
After  urethro-vesical  lavage  with  boric  acid  solution, 
a  silver  sound  is  passed — a  straight  one  for  the  anterior, 
or  a  curved  one  for  the  posterior  urethra.  The  current 
is  continued  for  ten  or  fifteen  minutes,  and  then 
reversed  for  a  few  minutes  before  extracting  the 
sound.  If  removal  of  the  sound  is  attempted  without 
changing  the  direction  of  the  current  the  sound  will 
be  found  firmly  adherent  to  the  urethral  walls. 


CHRONIC   GONOCOCCAL   URETHRITIS    149 


Medicated  Bougies,  Ointments,  etc. 

Medicated  bougies  are  disappointing  in  their  remedial 
effects,  and  are,  on  the  other  hand,  a  frequent  cause  of 
irritation.  If  a  bougie  is  inserted  into  the  anterior  ure- 
thra at  night  the  remnants  may  find  their  way  into 
the  posterior  urethra,  thence  to  the  bladder,  with  a 
consequent  cystitis  or  epididymitis. 

Ointments  are  only  of  use  for  the  purpose  of  pro- 
tecting an  eroded  or  excoriated  surface  from  contact 
with  the  urine.  There  are  several  types  of  urethral 
ointment  introducers.  Any  antigonococcal  medica- 
ment may  be  combined  with  a  lanoline  base.  The 
addition  of  glycerine  or  oil  renders  the  ointment  more 
fluid. 

Sohindler^s  agar  jelly. — For  early  chronic  or  late 
subacute  cases  Schindler  recommends  the  injection 
of  an  agar  jelly  with  ^  per  cent  protargol  incor- 
porated.    His  prescription  is — 

^  Agar  jelly  (2-5  per  cent)      ...        40 
Dissolve  with  gentle  heat  and  add  dis- 
tilled water  .  .  .  .  .160 

When  cold  sprinkle  on  the  surface  pro- 
targol ......  1 

Allow  to  stand  some  hours,  then  mix  thoroughly 
with  a  glass  rod. 

This  jelly  is  sufficiently  thin  to  be  injected  with 
a  small  urethral  syringe.  Harrison  and  Harold 
recommend  that  this  injection  should  be  expelled 
by  urination  in  ten  or  fifteen  minutes.  It  has  a 
marked  gonococcicidal  effect,  but  if  retained  too  long 
it  may  irritate  unduly.     The  reaction  must  then  be 


150   GONORRH(EA  &  ITS  COMPLICATIONS 

controlled  either  by  reducing  the  percentage  of  pro- 
targol  or  the  duration  of  the  retention  period.  Its 
consistence  ensures  that  a  proportion  remains  in 
contact  with  the  urethral  mucosa  until  the  next 
urination. 


CHAPTER   VIII 

THE    URETHROSCOPE  IN   THE   DIAGNOSIS   AND 
TREATMENT   OF    CHRONIC   URETHRITIS 

A  COMPLETE  comprehension  of  the  various  infective 
conditions  which  are  productive  of  a  chronic  urethral 
irritation  and  discharge  is  impossible  without  re- 
course to  endoscopic  examination  of  the  urethra. 
Through  the  urethroscope  as  now  perfected,  the 
whole  surface  of  the  urethral  mucosa,  both  anterior 
and  posterior,  with  its  communicating  orifices,  can  be 
inspected,  and  pathological  conditions  can  be  treated 
under  the  direct  control  of  the  eye. 

The  insertion  of  an  urethroscope,  like  all  other  in- 
strumentation, is  inadmissible  in  acute  conditions, 
but  the  urethroscope  plays  an  invaluable  role  in  cases 
of  delayed  resolution  and  in  cases  where  ordinary 
treatment  fails  to  completely  cure  the  infection  and 
remove  all  traces  of  discharge— that  is  to  say,  in  pro- 
longed subacute  and  in  chronic  conditions.  In  these 
cases  the  requisite  treatment  can  only  be  determined 
upon  after  an  exact  diagnosis  of  the  particular  lesion 
which  is  responsible  for  the  continuance  of  the 
symptoms.  In  many  cases  accuracy  is  obtainable 
only  by  the  use  of  the  urethroscope,  and  in  some  cases 
the  necessary  treatment  can  only  be  effected  through 
the  urethroscopic  tube.  The  urethroscope  is  as  in- 
dispensable to  the  urologist  as  the  laryngoscope  or 
ophthalmoscope    to    the    respective    speciaHsts.      A 

151 


152    GONORRHOEA  &  ITS  COMPLICATIONS 

familiarity  with  the  instrument  and  the  normal  and 
abnormal  appearances  which  can  be  viewed  wit^i  its 
assistance  is  therefore  essential  to  all  practitioners  of 
urology. 

History  of  the  urethroscope. — The  desirability  of 
endoscopic  inspection  of  the  urethra  prorripted  several 
early  attempts  to  illuminate  the  urethra,  but  the 
primitive  lighting  methods  then  available  rendered 
these  interesting  efforts  abortive.  Desormeux  (1853) 
is  responsible  for  the  first  practical  instrument,  and  his 
treatise  on  e^idoscopy  of  the  urethra  stimulated  a 
succeeding  generation  to  improve  on  his  methods. 
The  first  urethroscope  consisted  of  funnel-shaped  ure- 
thral tubes  or  specula  into  which  sunlight  or  artificial 
light  was  reflected  by  mirrors.  The  advent  of  electric 
light  gave  a  fresh  impetus  to  urethroscopy,  and 
enabled  it  to  take  an  important  place  in  clinical  work. 
Nitze,  in  1877,  introduced  a  novel  method  of  lighting. 
Inside  the  urethroscopic  tube  he  placed  a  small  brass 
tube  containing  a  platinum  wire  which  projected  a 
short  distance  beyond  its  container.  An  electric 
current  passing  along  the  platinum  and  returning 
by  the  brass  heated  the  platinum  to  a  red  glow 
which  illuminated  the  interior  of  the  urethra.  This 
apparatus  had  to  be  kept  cool  by  circulating  water. 
The  use  of  a  minute  electric  cold  lamp  suggested  by 
Drs.  Kock  and  Preston,  of  Rochester,  and  adopted 
by  Valentine  in  1903,  has  made  internal  lighting  of 
real  practical  utility. 

The  instruments  now  employed  for  the  anterior 
urethra  fall  into  two  classes  :  — 

(a)  Those  in  which  the  light  is  reflected  from  an 
external  electric  lamp,  and  focussed  at  the 
end  of  the  urethroscopic  tube ; 

{h)  those  in  which  the  light  is  obtained   from    a 


FULL  SIZES 


^ 


Fig.  47. 

A.  Wyndham  Powell's  aero-urethroscope. 

B.  Do.  do.       with  operating  attachment. 

C.  Instruments  for  use  with  B. 


154    GONORRHCEA  &  ITS  COMPLICATIONS 

minute  lamp  fixed  near  the  internal  end  of 
the  urethroscopic  tube. 

It  will  be  necessary  to  give  a  short  description  of 
a  recent  model  of  each  of  these  types. 

Perhaps  the  best  example  of  the  externally  illu- 
minated urethroscope  is  the  instrument  designed  by 
Wyndham  Powell  (Fig.  47).    In  this  urethroscope  the 
urethral  tube  is  fitted  with  a  protecting  cup,  which 
fits   over  the  glans,   and   each   tube   has   a   neck   of 
uniform  size  into  which  the  nozzle  carrying  the  lens 
is   inserted   after  the   obturator  has   been   removed. 
The  lamp  when  in  position  is  at  right  angles  to  the 
tube,  and  the  light  is  reflected  by  a  movable  mirror 
placed  above  the  lamp.    A  sliding  cross-bar  connects 
the  lamp  and  handle  with  the  upright  supporting  the 
lens.     From  the  nozzle  of  the  lens  portion  projects  a 
narrow  tube  with  stopcock  to  which  a  rubber  bellows 
can  be  attached  for  inflating  the  urethra.     The  use 
of  a  telescope  ensures  a  clear  view  of  the  distended 
anterior  urethra.     For  the  purpose  of  operating  on 
the  inflated  urethra  a  collapsable  rubber  drum  can 
be   inserted   between   the   lens   nozzle   and   the   ure- 
throscopic   tube.      The    probe    or    knife    which  it  is 
desired  to  introduce  into  the  urethra  is  fixed  into  a 
female  screw  inside  the  collapsable  mechanism.     The 
urethroscope  thus  becomes  the  handle  of  the  probe. 
By  screwing  up  the  rubber  drum  the  probe  is  made 
to  project  beyond  the  urethral  tube,  and  on  tilting 
the  urethroscope  in  the  desired  direction  the  mucous 
membrane   can   be   probed,    cauterized,   or  cut.     In 
addition  to  knives  and  probe,  a  curette,  electrolytic 
needle,  or  a  fine  syringe  can  be  employed  in  a  similar 
manner.     For  electrolysis,   as  the  rubber  mount  is 
already  insulated,  all  that  is  necessary  is  to  fix  the 
negative  wire  to  the  metal  part  of  the  urethroscope, 


CHRONIC   URETHRITIS 


155 


the  other  pole  being  placed  on  the  patient's  thigh. 
A  three-filament  lamp  is  used,  and  a  current  up  to 
eight  volts  is  required.  The  power  can  be  obtained 
either  from  an  accumulator  or  from  the  main  with 
the  interposition  of  a  suitable  rheostat. 

Much  useful  treatment  can  be  carried  out  Avithout 
the  aero-dilating  fitment  by  removing  the  lens  after 
locating  the  point  to  be  attacked  and  approaching 
it  through  the  open  lighted  tube. 


Fig.  48. 
Luys's  urethroscope. 

As  a  representative  of  the  second  type  of  urethro- 
scope, that  with  the  internal  lamp,  we  may  take  the 
instrument  of  Valentine  as  improved  by  Luys  of 
Paris  (Fig.  48).  This  urethroscope  consists  of  two 
portions — {a)  the  urethroscopic  tube  with  its  obtura- 
tor, (b)  the  electric  fitting.  The  tubes  vary  in  length 
according  to  the  part  of  the  urethra  to  be  explored, 
and  in  diameter  according  to  the  capacity  of  the 
meatus.  For  the  penile  urethra  a  tube  seven  centi- 
metres long  is  provided.     For  the  posterior  urethra 


156    GONORRHCEA  &  ITS  COMPLICATIONS 

the  tubes  measure  fourteen  centimetres.  The  medium 
tubes,  which  are  those  most  frequently  useful,  are 
thirteen  centimetres  in  length,  and  they  allow  the 
whole  urethra  anterior  to  be  examined. 

The  diameter  which  the  average  urethra  can 
accommodate  with  comfort  is  about  equal  to  number 
twenty-six  on  the  French  scale,  but  on  account  of  the 
larger  field  of  observation  the  largest  admissible  tube 
should  be  employed. 

The  tubes  are  not  perfectly  cylindrical.  A  groove 
for  the  reception  of  the  lighting  rod  runs  along  the 
bottom  of  the  tube.  The  sinking  of  the  lamp  carrier 
is  a  distinct  improvement  on  the  original  Valentine 
model,  giving  as  it  does  an  unobstructed  approach  to 
the  urethral  mucosa.  The  tubes  and  obturator  are 
made  of  plated  metal,  and  they  can  therefore  be 
boiled  without  damage. 

The  electric  fitting  comprises  a  metal  plate  with  a 
switch,  and  it  is  bored  at  the  lower  end  with  two 
apertures  for  the  poles  of  the  battery,  and  near  the 
upper  end  with  two  holes,  one  for  the  reception  at  a 
right  angle  of  the  lamp  carrier,  and  the  other  for  a 
corresponding  peg  on  the  urethroscopic  tube.  The 
plate  acts  as  a  handle,  and  carries  at  its  upper  part 
a  removable  magnifying  lens.  The  length  of  the 
lamp  holder  is  such  as  to  bring  the  lamp  as  near  to 
the  end  of  the  tube  as  possible  without  touching  the 
mucous  membrane. 

The  electrical  portion  can  be  sterilised  by  formaline 
vapour.  The  lamps  are  easily  interchangeable,  and 
several  should  be  kept  in  stock.  They  give  off  very 
little  heat  when  comparatively  new,  but  they 
should  not  be  too  long  in  use.  There  is  no  need 
to  fear  any  ill-effects  from  overheating  of  the 
lamp.     After    two     or    three    minutes'    burning    it 


CHRONIC   URETHRITIS  157 

registers  at  the  most  a  temperature  of  41°-43°  C. 
A  one-volt  dry  cell  gives  sufficient  current  for  these 
small  lamps. 

Perfect  illumination  and  an  unimpeded  view  is 
obtained  with  this  easily-handled  and  simple  instru- 
ment. The  lightness  and  portability  of  the  apparatus 
are  greatly  in  its  favour.  It  can  be  fitted  with  aero- 
dilating  connections,  but  Luys  does  not  specially 
recommend  this  addition. 

Gordon,  of  Vancouver,  has  designed  a  very  in- 
teresting urethroscope  (Fig.  49),  which  is  particularly 
suited  for  operative  work  within  the  urethra,  while 
the  canal  is  dilated  with  air.  Like  the  Valentine 
instrument,  it  is  internally  lit.  It  is  furnished  with 
two  changeable  magnifying  windows,  one  for  diag- 
nostic purposes  and  the  other  with  an  opening  for 
instruments. 

"  The  comparative  disadvantages  of  the  ordinary 
non-dilating  urethroscope  are  that  it  allows  of  a  view 
of  a  somewhat  limited  area  of  the  urethra  at  one 
time  as  the  mucous  membrane  rosettes  into  an  open 
end,  and  since  the  non-dilating  instrument  has  first 
to  be  introduced  to  the  triangular  ligament,  all  pus 
beads  marking  the  orifices  of  the  crypts  of  Morgagni, 
etc.,  are  displaced.  Moreover,  operating  on  the  cushion- 
like folds  of  the  undistended  urethra  is  most  difficult. 

Hence  many  attempts  have  been  made  to  devise 
a  practicable  dilating  urethroscope,  the  great  diffi- 
culty having  been  to  design  one  that  would  give  the 
right  degree  of  distension,  a  good  light,  large  field, 
and  direct  view,  while  leaving  the  operator's  hands 
free.  The  distension  is  given,  according  to  Dr. 
Gordon's  practice,  by  the  patient  himself  by  pressure 
on  the  dilating  bulb  when  asked.  The  lamp  is  at  the 
distal  end,  out  of  the  line  of  sight,  being  passed  in  on 
a  light  carrier  through  our  auxiliary  tube,  gives  no 
back  reflections  into  the  main  tube  and  cannot  be 


flH 


CHRONIC  URETHRITIS  159 

broken  by  instruments  passed  into  the  tube.  A 
marked  improvement  has  recently  been  made  in  the 
hghting  of  this  instrument  whereby  the  auxihary  tube 
for  the  hght  carrier  has  been  carried  out  to  the  very 
end  of  the  main  tube  and  left  entirely  open  at  its 
distal  extremity,  so  that  the  light  shines  forward, 
brilliantly  illuminating  the  dilated  urethra.  To  fill 
the  end  opening  of  the  auxiliary  tube  during  intro- 
duction the  obturator  has  been  provided  with  a 
movable  lug  on  a  spring. 

After  introduction  into  the  urethra  just  beyond 
the  fossa  navicularis,  the  obturator  is  withdrawn  and 
the  magnifying  window  inserted.  The  patient  is  then 
asked  to  press  the  bulb,  dilation  of  the  urethra 
follows,  the  tube  is  gradually  advanced  until  the 
sphincter  of  the  bladder  is  reached — and  the  whole 
passage  has  been  examined  with  a  minimum  of  dis- 
comfort. 

The  operating  instruments  are — 

1.  An  electro-cautery  for  warts. 

2.  A    curette    for    papillomata    and    pedunculated 

warts,  the  end  of  the  urethroscope  being  laid 
against  the  base  of  the  tumor,  the  curette 
advanced  beyond  it  and  withdrawn  so  as  to 
catch  the  tumor  between  the  curette  and  the 
edge  of  the  tube. 

3.  A  probe-pointed  knife. 

4.  A  syringe  for  injecting  the  crypts  of  Morgagni. 

5.  A  carrier  for  a  filiform  bougie. 

The  spiral  spring  on  the  shank  of  each  instrument 
prevents  it  from  dropping  beyond  the  tube  before 
required  for  operation.  Two  magnifying  windows 
are  furnished,  one  for  observation,  and  the  other, 
perforated,  for  use  with  operating  instruments.  The 
Gordon  urethroscope  is  13  centimetres  long  and  25, 
French,  in  calibre." 

An  externally  lit  operating  urethroscope  with 
several  novel  features  has  recently  been  devised 
by  Joly   ("Lancet,"   10/1/1914).     A  rubber   fitment 


160    GONORRHCEA  &  ITS  COMPLICATIONS 

allows  the  insertion  and  manipulation  of  instruments 
through  an  opening  in  the  lower  margin  of  the  win- 
dow. The  illustrations  (Fig.  50)  sufficiently  denote 
the  mechanism. 

Urethroscopes  for  the  posterior  urethra. — External 
lighting  is  not  satisfactory  for  examination  of  the 
posterior  urethra.  It  is  difficult  to  get  a  sufficient 
illumination  reflected  the  necessary  distance  down 
the  lengthened  tube.  The  delicate  structures  in  the 
posterior  urethra  are  some  distance  from  the  eye,  and 
yet  they  require  to  be  minutely  examined.  Magnifica- 
tion and  good  lighting  are  therefore  essential,  and 
this  can  only  be  obtained  by  means  of  an  internal 
lamp  and  an  accessory  optical  tube. 

Luys  uses  and  recommends  the  urethroscope  which 
he  employs  for  the  anterior  urethra,  the  only  differ- 
ence being  the  substitution  of  a  longer  (14  centimetres) 
urethral  tube.  For  some  particular  purposes  this 
tube  is  useful,  and  when  special  skill  in  its  manipula- 
tion has  been  acquired  it  may,  as  in  Luys's  hands, 
prove  satisfactory.  But  there  are  several  objections 
to  the  general  use  of  this  type  of  instrument  for  the 
posterior  urethra.  The  introduction  of  a  straight 
tube  is  attended  with  some  difficulty,  and  is  liable 
to  injure  the  sensitive  structures  in  the  posterior 
urethra,  especially  when  these  are  inflamed.  Bleeding 
may  ensue  and  be  difficult  to  control,  preventing  any 
examination  at  that  sitting.  Again,  it  cannot  be 
pushed  far  into  the  prostatic  urethra,  otherwise  it 
may  tap  the  bladder  with  a  consequent  escape  of 
urine  into  the  tube.  The  use  of  an  elbowed  obturator 
greatly  facilitates  the  introduction  of  a  straight  tube. 

The  best  form  of  instrument,  however,  for  posterior 
urethroscopy  carries  its  light  in  the  distal  end  of  a 
closed  and  elbowed  tube  with  an  aperture  through 


Joly's  urethroscope,  show- 
ing a  probe  mounted  in 
position. 


The  cautery  point  and  electrolysis  needle. 


Curette,  knife,  and  probe  designed 
for  the  urethroscope.  The  rubber 
"  cones  "  are  shown  mounted  in 
position. 


Fig.  50 


WATSON. — M 


162    GONORRHCEA  k  ITS  COMPLICATIONS 

which  the  mucosa  is  inspected.  Such  an  instrument 
may  be  fitted  with  an  air  or  water  dilating  attach- 
ment, and  also  with  a  telescope. 

There  are  three  urethroscopes,  all  of  which  are 
good. 

Goldsch7nidfs  is  a  water  dilating  urethroscope,  and 
is  built  on  the  principle  of  the  irrigating  cystoscope. 
The  water  flows  from  an  irrigator  into  the  posterior 
urethra,  which  it  dilates  and  then  overflows  into  the 
bladder.  The  whole  floor  of  the  posterior  urethra 
can  be  examined,  and  the  various  objects,  being 
magnified  and  well  lit,  can  be  studied  in  detail.  The 
upper  wall  of  the  urethra  is,  however,  not  within  the 
field  of  vision. 

Buerger's  cysto-urethroscope  contains  some  improve- 
ments on  the  above  pattern.  The  bladder  as  well  as 
the  whole  surface  of  the  posterior  urethra  can  be 
inspected  by  this  instrument. 

The  objection  to  water-circulating  urethroscopes 
is  that  the  pressure  of  the  water  alters  the  appear- 
ance of  the  parts,  rendering  the  mucosa  of  a  universal 
paleness,  so  that  one  of  the  main  diagnostic  appear- 
ances is  lost. 

The  Wossidlo  urethroscope  (Fig.  51)  is  so  con- 
structed that  the  posterior  urethra  can  be  lightly 
distended  with  a  small  quantity  of  air  if  desired,  but 
a  very  satisfactory  examination  is  possible  without 
the  air  distension.  It  is  perhaps  better  to  dispense 
with  the  air  distension,  as  some  air  might  escape  into 
the  bladder,  and  this  is  objectionable.  The  elbowed 
end-piece  is  removable,  and  two  are  supplied,  which 
allows  of  the  window  being  on  either  the  upper  or 
under  surface  of  the  tube,  according  to  whether  the 
roof  or  the  floor  of  the  urethra  is  to  be  explored. 

Once  the  technique  of  the  above  instruments  has 


CHRONIC  URETHRITIS 


163 


been  mastered,  almost  equally  good  results  will  be 
obtained  from  the  use  of  any  of  them;  but  two 
instruments,  one  either  Joly's  or  Luys's  for  the 
anterior  urethra,  and  one  of  these  above  described 
for  the  posterior  urethra  (preferably  the  Wossidlo), 
are  necessary  for  a  complete  outfit. 

The  insertion  of  the  urethroscope. — The  urethroscope 
should  not  be  inserted  without  a  preliminary  explora- 
tion of  the  patient's  urethra  and  an  examination  of 
the  urine.     It  is  not,  therefore,  employed  at  the  first 


Fig.  51. 
The  Wossidlo  urethroscope. 

consultation.  On  this  occasion  the  surgeon  satisfies 
himself  of  the  absence  of  any  acute  inflammation  of 
the  urethra,  prostate,  bladder,  or  epididymes  ;  and 
finally  of  the  absence  of  any  stenosis  of  the  meatus 
or  stricture  of  the  urethra  by  the  use  of  the  acorn 
bougie.  If  necessary,  the  urethra  is  subjected  to 
dilatation  treatment  before  the  urethroscopic  exam- 
ination is  attempted. 

On  the  day  fixed  for  the  examination  the  patient 
should  not  pass  urine  for  some  hours  previous  to  the 
appointment,  as  the  pathological  conditions  are  then 


164    GONORRHCEA  &  ITS  COMPLICATIONS 

seen  in  a  more  pronounced  form.     The  patient  lies 
with  the   pelvis  reaching  the   end   of  the   couch   or 
table,  and  with  the  legs  separated  and  supported  on 
foot  rests  or  leg  supports.     The  position  is  identical 
with  that  for  cystoscopy.    The  glans  and  meatus  are 
cleansed,    and    the    urethral    tube    lubricated    with 
sterile  glycerine  and  with  the  obturator  in  position 
is   inserted  its   full  length.     The   obturator  is  then 
withdrawn  and  the  urethra  cleared  of  secretion  by 
the   use  of   fine  wool-wrapped    probes.     The   light- 
ing   connections    are    then    made    and    the    urethra 
examined  from  behind  forwards  by  the  gradual  with- 
drawal   of    the    urethroscope.      When    finished    the 
patient  cleanses  the  urethra  by  passing  urine.     It  is 
advisable  to  prescribe  a  urinary  antiseptic  for  a  day 
or  two  before  and  after  the  examination,  and  also 
rectal  suppositaries  of  atropine.     Local  anaesthetics 
are   seldom  required   in   cases   suitable   for  urethro- 
scopy, but  when  a  particularly  nervous  patient  or  a 
specially  tender  mucosa  requires  desensitisation,  aly- 
pin  2  per  cent  should  be  used  instead  of  cocaine  or 
betaeucaine.     Contact  with  cocaine  renders  the  mu- 
cous   membrane    anaemic,  while    betaeucaine    tends 
to  produce  a  flushing  of  the  mucosa,  and  pathological 
conditions  are  in  either  case  obscured. 

The  appearance  of  the  normal  anterior  urethra  as  seen 
through  the  urethroscope. — In  the  resting  state  the 
walls  of  the  urethra  are  in  apposition,  and  are  thrown 
into  longitudinal  folds.  On  looking  through  the 
urethroscope  it  is  seen  that  the  urethra  distended  by 
the  endoscopic  tube  resumes  its  normal  collapsed 
condition  at  a  point  beyond  the  end  of  the  instrument 
where  the  stretching  effect  is  lost.  It  is  this  area  of 
mucosa  between  the  closing  urethral  lumen,  "  the 
central  figure,"  and  the  edge  of  the  tube  which  has 


CHRONIC   URETHRITIS  165 

to  be  examined  with  special  reference  to  its  colour, 
lustre,  duplicature,  and  striation. 

The  longitudinal  folds  are  separated  by  lines  of 
increasing  depth  converging  towards  the  central 
figure.    There  are  normally  four  to  ten  of  these  folds. 

The  longitudinal  strice,  which  in  addition  to  the 
folds  are  found  in  the  urethral  mucosa,  are  not  in 
reality  straight  lines,  but  they  appear  so  when  uni- 
formly stretched  by  the  urethroscope.  They  are 
vascular  streaks  of  a  fairly  bright  red  colour  radiating 
from  the  central  figure.  Tilting  the  tube  enables 
them  to  be  studied  in  their  natural  state.  They  are 
seen  most  clearly  on  the  roof,  and,  like  the  longitudinal 
folds,  are  most  prominent  in  the  well-developed  penis 
of  robust  subjects. 

The  central  figure  varies  in  outline  at  different 
points  of  the  canal.  Holding  the  endoscopic  tube 
with  gentle  traction  exactly  parallel  with  the  urethra 
ensures  the  central  position  of  the  figure.  In  the  bulb 
it  appears  as  a  perpendicular  fissure,  but  if  the  pos- 
terior urethra  is  approached  the  bulging  floor  of 
the  urethra  gives  it  a  semilunar  outline.  In  the  pars 
pendulosa  it  is  a  rounded  fossette  or  a  transverse  slit, 
while  in  the  glans  it  forms  a  perpendicular,  slightly 
oval,  or  triangular  fissure. 

The  colour  of  the  mucous  membrane  appears  as  a 
pale  yellow  transfused  with  a  dull  red  tint.  The  red 
is  most  in  evidence  posteriorly  ;  it  shades  off  to  rose- 
pink  in  the  pars  pendulosa,  and  in  the  glans  the  red 
is  almost  absent.  The  colour  varies  in  different  in- 
dividuals and  at  different  times  in  the  same  in- 
dividual. Thus  Luys  noticed  that  a  sudden  blanching 
of  the  mucosa  may  occur  simultaneously  with  blanch- 
ing of  the  face  and  indicate  the  onset  of  a  fainting 
attack.    As  the  red  colour  depends  on  the  vascularity 


166    GONORRHCEA  &  ITS  COMPLICATIONS 

of  the  mucous  membrane  it  is  influenced  by  the  pres- 
sure of  a  large  tube,  the  amount  of  traction  practised, 
and  the  apphcation  of  local  anaesthetics. 

Lustre. — The  healthy  mucous  membrane  has  a 
uniformly  smooth  and  glistening  surface. 

One  or  more  of  the  large  lacunce  are  frequently  dis- 
tinguishable on  the  roof  of  the  anterior  part  of  the 
urethra.  They  form  triangular  pockets,  the  apex  of 
the  triangle  being  directed  towards  the  central  figure. 

The  small  lacunae  as  well  as  the  glands  of  Littre  and 
the  orifices  of  Cowper's  glands  are  not  visible  in 
health  unless  considerably  magnified. 

The  normal  posterior  urethra  as  seen  through  the 
urethroscope. — The  most  important  part  of  the  pos- 
terior urethra  is  the  region  of  the  verumontanum. 
In  fact,  the  floor  of  the  posterior  urethra  is  the  seat 
of  the  great  majority  of  the  lesions  which  require 
attention,  and  therefore  in  using  the  Wossidlo  ure- 
throscope the  end-piece  which  allows  of  this  surface 
being  examined  should,  in  the  first  instance,  be  used. 

The  prostatic  urethra  is  a  deeper  red  than  any 
other  portion  of  the  urethra.  Behind  the  verumonta- 
num, the  prostatic  fossette  is  seen  extending  to  the 
neck  of  the  bladder.  The  mucosa  of  the  floor  is 
thrown  into  folds  radiating  from  the  neck  of  the 
bladder  in  a  fan-shaped  manner.  As  the  urethroscope 
is  withdrawn  the  verumontanum  bulges  into  view.  On 
the  front  aspect  of  the  apex  of  the  mound  the  pros- 
tatic utricle  may  be  seen  as  an  oval  slit,  and  in  the 
sulci  on  either  side  some  of  the  ducts  of  the  prostate 
may  be  visible.  The  openings  of  the  ejaculatory 
ducts  are  not  usually  seen  ;  but  they  may  be  found 
on  or  near  the  lips  of  the  prostatic  utricle,  or  they 
may  be  placed  in  the  grooves  at  the  side  of  the  veru- 
montanum. Continuing  forwards,  the  verumontanum 


CHRONIC  URETHRITIS  167 

is  seen  running  into  the  urethral  crest,  which  loses 
itself  in  the  membranous  urethra. 

In  formation  the  verumontanum  shows  a  consider- 
able amount  of  variety.  It  is  usually  about  the  size 
of  a  split  pea,  but  it  may  be  so  small  as  to  be  difficult 
to  locate,  or  so  large  as  to  fill  the  whole  prostatic 
urethra.  Occasionally  it  assumes  a  cock's-comb 
appearance.  In  colour  it  is  usually  a  shade  paler 
than  the  neighbouring  mucous  membrane. 

DISEASED   CONDITIONS    OF    THE    ANTERIOR   URETHRA 
AS   SEEN  THROUGH   THE   URETHROSCOPE 

A  provisional  diagnosis  of  the  position  and  nature 
of  a  chronic  gonococcal  or  post-gonorrhoeal  lesion  is 
possible  by  the  use  of  the  button-headed  probe,  the 
scrutiny  of  the  urinary  and  other  washings  of  the 
urethral  channel,  and  the  microscopic  examination  of 
the  secretions  ;  but  when  depending  alone  on  these 
diagnostic  measures  the  risk  of  error  is  considerable, 
and  in  no  case  can  a  diagnosis  be  made  with  any 
definite  assurance  of  accuracy  without  having  re- 
course to  the  urethroscope.  A  mere  list  of  the 
lesions  which  can  be  demonstrated  through  the  ure- 
throscope will  prove  the  justice  of  this  statement. 

1.  Infiltrations:  (a)  soft; 

(b)  hard. 

2.  Glandular  disease  :  (a)  with    pouting    and    in- 

flamed orifice  ; 
(b)  with  closed  orifice,  cystic. 

3.  New  growths  :  (a)  condylomata  acuminata  ; 

(b)  polypi. 

4.  Erosions  and  granulations. 

5.  Fissures. 

6.  Epithelial  excrescences. 


168    GONORRHCEA  &  ITS  COMPLICATIONS 

Of  these  only  the  gross  forms  of  infiltration  can 
be  differentiated  with  any  certainty  apart  from  ure- 
throscopy, and  it  is  obvious  that  no  general  scheme 
of  treatment  suitable  for  all  of  these  conditions,  and 
therefore  applicable  to  every  case  of  chronic  gonor- 
rhoea, could  be  proposed.  Success  in  the  treatment  of 
many  chronic  gonorrhoeas  is  thus  dependent  on  a 
thorough  and  complete  diagnosis,  which  is  possible 
only  with  the  help  of  the  urethroscope. 

Infiltrations. — It  is  to  the  work  and  teaching  of 
Oberlaender  that  we  owe  our  knowledge  of  this  sub- 
ject. He  divides  infiltrations  into  two  main  groups, 
the  soft  and  the  hard  ;  but  a  considerable  proportion 
are  mixed  or  transitional,  and  all  forms  may  be 
present  in  the  same  urethra. 

Soft  infiltrations  are  present  in  acute  urethritis. 
In  the  event  of  the  continued  survival  of  the  gonococ- 
cus  the  infiltrated  areas  surrounding  the  infected  sites 
fail  to  undergo  absorption.  The  mucous  membrane 
at  these  points  remains  swollen  and  hypersemic,  but 
as  there  is  no  appreciable  narrowing  of  the  urethral 
lumen,  no  obstruction  is  offered  to  the  introduction 
of  the  urethroscope.  A  single  soft  infiltration  may  be 
found  or  several  may  be  present  at  the  same  time. 
They  are  most  frequently  situated  in  the  pendulous 
urethra,  especially  in  the  neighbourhood  of  the  peno- 
scrotal angle,  less  often  in  the  bulb,  but  they  may  be 
found  in  any  part  of  the  urethra]  mucosa. 

The  increased  vascularity  of  these  areas  causes 
them  to  appear  more  vividly  red  than  the  healthy 
mucous  membrane.  They  bleed  readily.  The  intro- 
duction of  a  tube  or  swabbing  will  usually  produce 
some  oozing. 

The  epithelial  covering  in  the  earlier  stages  ap- 
pears  brightly  polished   and   glistening,   but   as   de- 


CHRONIC   URETHRITIS  169 

squamation  proceeds  the  lustre  is  lost,  and  minute 
erosions  or  bright  red  granulations  may  be  seen. 

The  longitudinal  folds  are  reduced  to  about  half 
their  normal  number,  and  they  are  not  so  well 
defined. 

The  striae  are  not  visible  in  the  infiltrated  area. 
The  central  figure  is  also  absent  in  well-marked  cases, 
and  in  other  cases  it  is  displaced  and  distorted. 

The  lacunae  of  Morgagni  are  always  abnormal. 
They  appear  as  pinhead  projections  with  red,  swollen, 
crater-like  orifices  exuding  a  muco-purulent  dis- 
charge. 

The  glands  of  Littre  are  not  seen  in  soft  infiltra- 
tions. 

Hard  infiltrations. — Oberlaender  usefully  but  arbi- 
trarily subdivides  hard  infiltrations  into  three  classes. 

Those  of  the  first  degree  are  cases  in  which  the 
lumen  of  the  urethra  is  not  markedly  contracted.  In 
those  of  the  second  degree  the  urethra  is  obstructed 
but  still  allows  the  passage  of  instruments  equal  to 
at  least  number  twenty-three,  Charriere.  In  the 
third  degree  only  instruments  smaller  than  twenty- 
three  can  be  inserted.  Classes  two  and  three  con- 
stitute what  are  generally  recognised  as  "  strictures." 

Hard  infiltrations  are  found  most  commonly  about 
the  middle  of  the  pendulous  urethra  and  in  the 
neighbourhood  of  the  bulb.  As  in  the  soft  variety, 
they  may  be  single  or  multiple.  Only  in  rare  cases 
is  there  a  sclerosis  of  the  entire  urethra. 

The  most  striking  feature  of  the  hard  infiltration, 
as  seen  through  the  urethroscope,  is  its  anaemic  ap- 
pearance. Progressively  with  the  deposit  of  fibrous 
tissue  in  an  infiltrated  area  the  blood-vessels  decrease 
in  size  and  number  until  finally  the  colour  is  reduced 
to  a  pale  yellow  or  dirty  white. 


170    GONORRHCEA  &  ITS  COMPLICATIONS 

In  early  cases  the  epithelium  has  lost  its  lustre, 
while  the  epithelial  surface  is  irregular,  in  part  ex- 
foliated and  in  part  hypertrophied  and  keratinized, 
with  projecting  points  or  even  small  excrescences. 

As  an  infiltration  becomes  more  fibrous,  the  longi- 
tudinal folds  continue  to  decrease  in  definiteness  and 
in  number  until  they  disappear  entirely,  and  the 
affected  area  presents  the  appearance  of  an  inelastic 
non-collapsible  tube. 

The  central  figure,  as  one  would  expect  in  such 
circumstances,  is  replaced  by  a  funnel-shaped  cavity. 

The  lacunae  and  the  glands  of  Littre  are  always 


Fig.  52. 
KoUmann's  suction  pipette. 

altered   in    appearance.    Oberlaender  described  two 
characteristic  changes — 

1 .  The  glandular  or  moist  form,  in  which  the  glands 
are  actively  excreting  inflammatory  products  and 
the  gaping  ducts  appear  as  minute  red  rings  covered 
with  secretion. 

2.  The  follicular  or  dry  form,  in  which  the  glands 
have  shrunk  and  atrophied  or  are  represented  by  closed 
follicles.  The  expression  "  dry  "  is  used  here  with 
reference  to  the  glands  only.  There  is  usually  some 
gleety  discharge  present  in  these  cases. 

Frequently  both  of  these  types  are  seen  in  the  same 
urethra,  especially  in  cases  undergoing  dilatation 
treatment.  The  conversion  of  the  dry  into  the  moist 
type  is  a  movement  in  the  direction  of  recovery,  and 
indicates  that  the  treatment  is  acting  beneficially. 


CHRONIC   URETHRITIS  171 

Papillomatous  growths  histologically  identical  with 
the  gonorrhoeal  warts  {Condylomata  acuminata)  which 
commonly  grow  in  the  preputial  sac,  are  occasionally 
found  in  the  urethra  on  making  an  endoscopic  ex- 
amination. Minute  papillary  projections  may  occur 
in  great  numbers.  They  have  been  seen  to  cover  the 
whole  mucous  membrane  of  the  urethra.  Flat  sessile 
warts  are  frequently  mistaken  for  erosions.  Large 
warts  are  easily  identified.  They  may  occasionally 
be  so  large  as  to  retard  the  flow  of  urine.  These 
mucous  membrane  warts  are  soft  and  friable.  In 
colour  they  are  different  shades  of  red.  They  can  be 
moved  about  and  their  base  defined  by  the  urethro- 
scopic  probe.  They  can  be  snared  or  curetted,  but  as 
a  rule  they  disappear  quickly  under  treatment  by  in- 
jections of  dilute  lactic  acid  (1  :  200)  or  limited 
applications  of  the  pure  acid  through  the  urethro- 
scope, and  this  method  avoids  the  formation  of  cica- 
trices which  may  narrow  the  lumen  of  the  urethra. 

Fissures  parallel  with  the  axis  of  the  urethra 
occur  even  apart  from  traumatism.  These  sluggish 
cracks  of  the  mucous  membrane  heal  after  careful 
dilatation  and  antiseptic  irrigation. 

Cysts. — In  addition  to  the  cystic  degeneration 
present  in  the  dry  form  of  hard  infiltration,  larger 
cysts  are  met  with  on  rare  occasions.  They  spring 
from  Littre  glands  as  a  rule,  but  blockage  of  the 
duct  of  a  Cowper's  gland  may  also  originate  a  large 
cyst. 

Diseased  conditions  of  the  posterior  urethra  as  seen 
through  the  urethroscope. — Urethroscopic  examination 
of  the  posterior  urethra  will  in  many  cases  reveal  a 
lesion  requiring  special  treatment  before  cure  can  be 
obtained.  Disease  of  the  verumontanum,  the  pros- 
tatic utricle,  and  prostatic  ducts  may  give  rise  to  no 


172   GONORRHCEA  &  ITS  COMPLICATIONS 

characteristic  physical  signs  which  would  enable  a 
definite  diagnosis  to  be  made  apart  from  direct  in- 
spection. 

The  posterior  urethra  may  be  the  seat  of  the  same 
pathological  lesions  as  are  seen  in  the  anterior 
urethra,  including  soft  and  hard  infiltrations,  erosions, 
and  papillomata. 

The  soft  infiltration  is  recognised  by  its  deep  red 
colour,  tendency  to  bleeding,  and  the  decreased  lustre 
of  the  epithelium.  This  is  the  common  lesion  in  the 
posterior  urethra. 

The  hard  infiltrations  are  distinctly  paler  than  the 
surrounding  membrane,  and  in  advanced  cases  are 
slate-grey  or  yellow  in  colour.  Owing  to  the  absence 
of  glands  they  resemble  the  dry  form  found  in  the 
anterior  urethra  rather  than  the  moist. 

Infected  prostatic  ducts  are  encircled  with  a  ring 
of  red  and  oedematous  mucous  membrane. 

The  prostatic  utricle  is  sometimes  the  seat  of  a 
chronic  inflammation.  Its  orifice  may  be  patulous 
with  a  congested  ridge-like  edge. 

The  verumontanum  furnishes  evidence  of  disease 
in  most  cases  of  chronic  posterior  urethritis.  Usually 
it  presents  the  features  of  a  soft  infiltration,  being 
swollen,  reddened,  and  bleeding  when  touched.  It 
may,  however,  be  sclerosed,  when  it  will  appear 
yellowish  red  and  wrinkled. 

Papillary  and  polypoid  growths,  1-2  centimetres  in 
length,  are  not  rare  in  the  posterior  urethra. 

When  one  remembers  that  the  posterior  urethra  is 
an  important  junction  in  the  sexual  circle,  disease  of 
which  is  liable  to  set  up  a  train  of  symptoms,  nervous 
and  toxic,  which  gains  momentum  the  longer  it  is 
allowed  to  run,  the  wisdom  of  an  early  and  careful 
examination  will  be  obvious. 


PLATE    VIII. 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Fig.  5. 


Fig.  6. 


Fig.  7. 


Fig.  8. 


Fig.  9. 


Fig..  .10. 


Fig.  1. — Normal  Urethral  Mucosa.  Fig.  2., — Chronic  Urethritis  with  Erosions.  Fig.  3. — Chronic 
Urethritis,  Vesicular.-  Fig.  4. — Stricture  of  the  Urethra.  Fig.  5. — Follicular  Abscess.  Fig.  6. — Cysts 
of  the  Mucosa.  Fig.  7. — Posterior  Urethra.  The  Verumontanum.  Fig.  8. — Papilloma  of  Prostatic 
Urethra.  Fig.  9. — Bi-lateral  Prostatic  Hypertrophy;  Posterior  Urethral  View.  Fig.  10. — Bi-lateral 
and  Median  Prostatic  Hypertrophy;  Posterior  Urethral  View. 


Anterior  and  Posterior  Urethroscopic  Pictures. 

"By  permission,  from  'The  Practice  of  Urology',  Chetwood." 


CHAPTER    IX 

NON-GONORRHCEAL    URETHRITIS    (URETHRITIS 
SIMPLEX) 

It  is  not  proposed  to  present  here  an  exhaustive 
study  of  the  various  forms  of  urethritis  due  to  other 
than  a  gonococcal  origin.  All  that  is  intended  is  a 
short  statement  of  such  inflammatory  conditions  of 
the  urethra  as  might  give  rise  to  the  suspicion  of 
gonococcal  infection. 

Urethritis  arising  from  mechanical,  chemical,  or 
thermal  irritation  is  generally  ascribed  to  its  proper 
source,  except  in  the  case  of  children.  Exploration  of 
the  urethra  will  determine  the  presence  or  absence 
of  foreign  bodies  mischievously  inserted  from  without, 
or  calculi  impacted  during  their  passage  from  the 
bladder  or  kidneys. 

Indirect  trauma,  especially  prolonged  bicycle  or 
horse  riding,  has  been  known  to  excite  symptoms  of 
urethritis.  In  these  cases  pain  in  the  perineum  and 
prostatic  tenderness  have  been  associated  with  a  mild 
muco-purulent  urethral  discharge. 

These  symptoms  are  particularly  liable  to  occur  in 
youths,  and  in  hot  weather  when  profuse  perspira- 
tion and  consequent  concentration  of  the  urine  tends 
to  excite  an  irritation  of  the  mucous  membrane. 

Chemical  urethritis  is  usually  due  to  prophylactic 
injections  of  domestic  antiseptics,  and  appearances 
simulating  a  true  gonorrhoea  may  thus  be  induced, 
but   microscopic   examination   of  the   secretion   will 

173 


174    GONORRHCEA  &  ITS  COMPLICATIONS 

show  that  the  gonococcus  is  absent.  Severe  pain, 
haemorrhage,  and  discharge  of  pus  and  fragments  of 
necrosed  tissue  may  result  from  the  use  of  unsuitable 
solutions  of  such  urethral  irritants  as  perchloride  of 
mercury  or  carbolic  acid.  The  anterior  urethra  is 
alone  implicated  in  these  cases,  and  cicatrization  may 
finally  end  in  stricture  formation.  In  traumatic 
urethritis  there  is  no  incubation  period.  The  inflam- 
matory reaction  appears  quickly  and,  if  the  exciting 
cause  is  removed,  soon  subsides,  unless  considerable 
damage  has  been  done  to  the  tissues.  Mild  cases  re- 
quire little  in  the  way  of  treatment.  Balsamics 
assist  in  decreasing  the  urinary  discomfort,  and  in 
severe  cases  cocaine  and  adrenalin  injections  may  be 
indicated.  Overdoses  of  certain  drugs  and  articles 
of  diet  have  been  responsible  for  urethral  discharge, 
e.g.,  cantharides,  asparagus,  rhubarb,  etc. 

Organisms  producing  urethritis  simplex. — Of  the 
pathogenic  organisms  which,  as  an  incident  in  a 
general  infection,  may  be  found  in  the  urethra,  men- 
tion may  be  made  of  the  typhoid  bacillus,  the  tubercle 
bacillus,  the  treponema  pallidum,  and  the  meningo- 
coccus ;  but  these  infections  are  not  likely  to  give 
rise  to  any  confusion  with  gonorrhoea. 

The  infective  agents  which  have  been  known 
occasionally  to  simulate  a  gonococcal  inflammation 
are — 

1.  The  micrococcus  catarrhalis. 

2.  The  bacillus  coli. 

3.  Staphylococci. 

4.  Streptococci. 

5.  The  influenza  bacillus. 

6.  The  pneumococcus. 

7.  Friedlander's  bacillus. 

8.  Diphtheroid  bacilli. 


NON-GONORRHCEAL   URETHRITIS     175 

A  few  cases  of  pneumococcus  urethritis  have  been 
reported. 

In  some  cases  in  which  the  gonococcus  could  not 
be  proved,  staphylococci  or  streptococci  have  been 
present  in  such  numbers  as  to  suggest  that  they  were 
the  etiological  factor  in  the  production  of  the  disease. 

The  influenza  bacillus  and  Friedlander's  bacillus 
have  been  found  together  in  a  few  cases. 

In  urethritis,  where  there  was  no  likelihood  of  a 
gonococcal  basis,  my  experience  is  limited  to  the 
bacillus  coli,  the  micrococcus  catarrhahs,  and  a  small 
staphylococcus  albus.  The  bacillus  coli  I  found  the 
causative  organism  in  a  subacute  urethritis  in  a 
young  boy  ;  the  micrococcus  catarrhalis  produced 
a  moderate  urethritis  in  a  young  married  man  ;  the 
staphylococcus  caused  little  evidence  of  inflammation 
in  the  male,  but  excited  an  acute  vaginal  discharge  in 
two  female  partners,  the  man  merely  acting  as  carrier 
probably  from  a  third  female. 

None  of  the  above  infections  excite  such  an  acute 
inflammation  as  does  the  gonococcus.  The  ure- 
thritis is  subacute  in  type,  and  tends  in  most  cases  to 
early  spontaneous  cure. 

The  diagnosis  depends  on  the  history,  on  the  mild 
course,  and  essentially  on  the  microscopic  and  cul- 
tural examination  of  the  secretion. 

It  is  possible  that  an  even  larger  number  of  bac- 
teria is  involved  in  female  genital  infections,  and  that 
the  male  acts  as  carrier  of  these  infections  without 
being  aware  in  his  own  person  of  any  condition  of 
disease  ;  but  of  course  the  mode  of  infection  is  not 
necessarily  venereal  either  in  the  male  or  female. 

There  is  considerable  variation  in  individual  sus- 
ceptibility. Fair  people  of  either  sex  are  more  liable 
to  infection,  and  are  more  difficult  to  cure. 


176    GONORRHCEA  &  ITS  COMPLICATIONS 

While  it  remains  true  that  these  cases  are  compara- 
tively rare,  the  possibility  of  a  non-gonococcal  genital 
infection  accentuates  the  advisability  of  the  micro- 
scopic control  of  each  case. 

Much  work  still  remains  awaiting  investigation 
on  this  subject. 


CHAPTER   X 

GONOCOCCAL   BALANITIS  AND   BALANO- 
POSTHITIS 1 

The  preputial  sac  being  lined  by  squamous  epithelium 
does  not  present  a  surface  suitable  for  the  activity  of 
the  gonococcus,  and  on  that  account  it  cannot  be  said 
that  a  gonococcal  invasion  of  the  tissues  of  the  inner 
layer  of  the  prepuce,  coronal  sulcus,  or  glans  is  of  fre- 
quent occurrence.  In  fact,  the  possibility  of  such  an 
event  is  denied  by  most  authorities.  That  this  as- 
sumption is  erroneous  will  be  proved  later,  but  prob- 
ably the  inflammatory  swelling  and  oedema  of  the 
prepuce  and  glans  so  commonly  encountered  in 
association  with  gonorrhoea  is  in  most  cases  pro- 
duced by  contact  with  the  irritating  urethral  dis- 
charge, and  the  gonococcus  in  the  preputial  sac  then 
plays  for  the  most  part  the  role  of  a  passenger.  As 
a  consequence  of  the  oedematous  swelling  of  the 
prepuce  a  condition  of  marked  phimosis,  in  which 
the  prepuce  cannot  be  retracted,  or  of  paraphimosis, 
in  which  the  retracted  foreskin  forms  a  constricting 
band  behind  the  glans,  may  follow,  and  unless  success- 
fully treated  ulceration  or  even  sloughing  may  re- 
sult. 

Anatomy. — The    modified    skin    which    forms    the 
inner  covering  of  the  prepuce  is  continued  over  the 

1  Balanitis  is  an  inflammation  of  the  glans,  and  Posthitis  is  an  inflamma- 
tion of  the  inner  lamella  of  the  prepuce.     Both  surfaces  are  usually  afi'ected. 

WATSON. — N  177 


178    GONORRHOEA  &  ITS  COMPLICATIONS 

glans,  and  enters  the  urethra  as  far  as  the  fossa 
navicularis.  It  is  destitute  of  mucous  glands,  but 
sebaceous  glands  are  present.  These  are  promi- 
nently seen  in  the  neighbourhood  of  the  coronal 
sulcus  (glands  of  Tyson)  (Fig.  53).  In  addition  to 
these  sebaceous  glands  there  are  minute  epithelial 
pits  scattered   over  the  surface,   but  they  have  no 


Fig.  53 

Showing  a  section  (much  magnified)  througli  one  of  Tyson's  glands  in  the 
prepuce  of  a  young  child.     (Taylor.) 

glandular  epithelium.  Two  specially  large  crypts, 
sometimes  also  spoken  of  as  glands  of  Tyson,  are 
frequently  to  be  found  one  on  either  side  of  the 
froenum. 

The  secretion  which  collects  in  the  sulcus  is  com- 
posed of  epithelial  debris,  sebaceous  material,  and 
micro-organisms . 

Bacteriology. — In  the  normal  preputial  cavity  vari- 
ous micro-organisms  are  found,  the  most  constant  of 
which  are  included  in  the  following  list  (Scherber)  : — 


GONOCOCCAL   BALANITIS  179 

1.  The  smegma  bacillus  is  a  long,  thin  bacillus, 
faintly  Gram-positive.  It  is  seldom  quite  straight, 
but  is  more  often  irregularly  curved  or  twisted,  and  in 
many  instances  is  seen  to  be  undergoing  segmentation. 

2.  A  diphtheroid  bacillus,  short,  Gram-positive. 
Club  shapes,  spindle  shapes,  and  swollen  or  thickened 
forms  are  seen. 

3.  A  Gram-negative  bacillus,  with  rounded  ends  like 
the  influenza  bacillus,  occurs  in  large  numbers. 

4.  A  Gram-positive  coccus,  which  lies  singly  or  in 
groups  of  two  or  more,  or  in  short  chains. 

5.  Bacillus  coli  group,  Gram-negative,  straight 
bacillus,  with  rounded  ends. 

6.  Vibrios,  with  tapering  ends  :  both  Gram-posi- 
tive and  Gram-negative  forms  are  seen. 

7.  SpirochcBtce.    Gram-negative  and  slender. 

8.  The  ordinary  pyogenic  staphylococci  and  strep- 
tococci are  also  found. 

It  will  be  seen  that  we  have  here  a  flora  with  a 
sufficiently  mischievous  potentiality  requiring  only 
the  production  qf  a  lesion  to  give  its  pathogenic 
members  their  opportunity.  Regular  cleansing  has 
a  marked  effect  in  reducing  the  numbers  of  these 
organisms,  and,  on  the  other  hand,  phimosis  favours 
their  growth. 

Balano-preputial  inflammation  may  arise  from 
causes  other  than  venereal  infection,  and  it  may  also 
be  produced  by  venereal  infection  in  which  the 
gonococcus  plays  no  part ;  but  at  the  moment  we 
are  only  concerned  with  the  condition  as  a  complica- 
tion of  gonococcal  urethritis.  The  presence  of  a 
urethritis,  in  cases  where  the  urethra  cannot  be 
inspected,  can  be  proved  by  the  appearance  of  the 
urine  passed  after  a  thorough  syringing  of  the  pre- 
putial cavity. 


180    GONORRHCEA  &  ITS  COMPLICATIONS 

Gonorrhoeal  balanitis  may  be  acute  or  chronic,  and 
the  symptoms  and  treatment  of  acute  disease  depend 
upon  the  relationship  of  the  prepuce  to  the  glans. 

Symptoms  of  acute  balanitis  with  phimosis. — In  this 
condition  the  long  prepuce,  with  its  narrowed  orifice, 
forms  a  sac  in  which  the  urethral  discharge  tends  to 
stagnate,  and  the  irritation  set  up  by  the  gonotoxine 
produces  an  acute  diffuse  inflammation  of  the  whole 
balano-preputial  surface,  which  becomes  swollen  and 
oedematous,  reducing  still  further  the  lumen  of  the 
orifice  and  preventing  drainage. 

When  the  inflammation  is  intense  one  or  more 
areas  of  necrosis  may  eventuate  with  a  perforation, 
usually  on  the  dorsal  surface,  through  which  the  glans 
may  present. 

The  treatment  may  be  expectant  or  operative. 

Expectant  treatment  consists  of  rest  in  bed  with 
elevation  of  the  penis,  and  frequent  cleansing  of  the 
preputial  cavity  by  means  of  a  large  syringe  or  an 
irrigator.  The  antiseptics  which  are  most  useful  are 
permanganate  of  potash,  nitrate  of  silver,  perchloride 
of  mercury,  aluminium  acetate,  and  lactic  acid. 
Previous  to  the  irrigation  the  pus  may  be  removed 
by  instilling  some  hydrogen  peroxide.  This  is  es- 
pecially beneficial  when  the  condition  is  complicated 
by  the  presence  of  soft  sores.  Operative  treatment  is 
indicated  in  hyperacute  conditions  and  cases  un- 
responsive to  a  few  days'  expectant  treatment.  The 
measures  which  may  be  adopted  are,  either  a  median 
dorsal  slitting  of  the  prepuce,  or  two  lateral  incisions, 
with  complete  circumcision  later ;  or,  in  suitable 
cases,  circumcision  may  be  undertaken  at  once. 

Paraphimosis  complicating  gonorrhoea  is  due  to 
inflammatory  swelling  of  a  short  or  retracted  foreskin. 
The  glans  is  congested  and  swollen,  and  oedematous 


GONOCOCCAL   BALANITIS  181 

tumefaction  occurs  in  the  region  of  the  frsenum  and 
also  on  the  dorsal  portion  of  the  everted  prepuce. 
The  constricting  band  is  not  the  preputial  limbus.  It 
consists  of  an  aggregation  of  the  circular  fibres 
found  in  the  connective  tissue  on  the  dorsum  of  the 
prepuce.  Reposition  of  the  glans  may  be  attempted 
by  efforts  to  express  the  oedema  and  congestion  from 
the  glans  and  the  bulging  parts  of  the  foreskin.  Com- 
pression by  elastic  bandaging  will,  in  a  few  minutes, 
considerably  reduce  the  swelling,  when  the  skin  of  the 
penis  may  be  pulled  forward  at  the  same  time  as  the 
glans  is  digitally  compressed  and  pushed  backwards. 
In  the  event  of  failure  of  this  method,  the  oedematous 
ring  may  be  subjected  to  multiple  puncturing  with  a 
small  sharp-pointed  bistoury,  a  moist  dressing  ap- 
plied, the  penis  elevated,  and  the  patient  kept  in  bed. 

In  spite  of  the  obvious  interference  with  the  cir- 
culation, sloughing,  in  the  absence  of  phagedenic 
ulceration,  seldom  or  never  occurs. 

Operative  treatment  is  therefore  only  adopted  with 
a  view  to  hasten  recovery. 

To  cut  the  constricting  fibres  a  fine,  sharp-pointed 
bistoury  is  inserted  through  the  skin  on  the  dorsum 
of  the  penis  proximal  to  the  constriction.  The  knife 
is  passed  forwards  in  the  subcutaneous  tissue  close 
to  but  carefully  avoiding  the  tunica  albuginea  until 
the  tightened  fibres  are  felt  and  severed,  when  the 
oedema  and  congestion  will  soon  subside  and  the 
prepuce  can  be  replaced. 

CHRONIC   GONOCOCCAL  BALANITIS 

Reference  has  already  been  made  to  the  prevalent 
opinion  that  gonococcal  invasion  of  the  tissues  of  the 
preputial  sac  does  not  occur.     If  this  were  so,  then 


182    GONORRHCEA  &  ITS  COMPLICATIONS 

chronic  gonococcal  balanitis  would  be  non-existent. 
In  order  to  refute  this  teaching,  one  of  the  cases  which 
have  come  within  the  writer's  experience  may  be 
quoted  : — 

A  bachelor  of  virtuous  habit  on  the  occasion  of 
an  unfortunate  lapse  over  eight  years  ago  con- 
tracted gonorrhoea,  which  ran  a  usual  course  and  was 
apparently  cured  within  six  weeks.  Since  then  he 
had  been  unconscious  of  any  disease  until  a  few 
months  ago,  when  he  developed  influenza,  which 
confined  him  to  bed  for  three  days.  It  had  been  his 
daily  practice  to  retract  the  elongated  prepuce  and 
wash  the  gians,  but  this  was  omitted  during  those 
three  days.  Three  days  later  a  urethritis  was  in 
evidence,  for  which  he  sought  my  advice.  The 
patient  strenuously  denied  the  possibility  of  any 
source  of  infection  other  than  the  neglect  of  his 
usulfe.1  toilet. 

On  retracting  the  prepuce  and  removing  the 
creamy  discharge,  the  glans  was  seen  to  be  red,  moist, 
and  finely  granular  over  one-third  of  its  surface,  and 
many  of  the  glands  of  Tyson  in  the  coronal  sulcus 
were  actively  inflamed.  A  tingling  heat  and  smarting 
were  complained  of  in  the  affected  parts.  After 
careful  cleansing,  scrapings  taken  from  the  surface 
of  the  glans  showed  numbers  of  gonococci  and  no 
other  organisms. 

This  case  well  illustrates  several  points  in  con- 
nection with  gonococcal  infection.  In  the  first 
place,  the  long  period  during  which  infectivity 
may  continue  is  proved  with  little  possibility 
of  error.  My  knowledge  of  the  patient  enables  me 
unhesitatingly  to  accept  his  word  with  regard  to  any 
subsequent  exposure  to  venereal  disease.  Then  it 
proves  that  a  relative  immunity  to  the  particular 


GONOCOCCAL   BALANITIS  183 

strain  of  gonococcus  is  acquired  by  the  urethra,  as 
the  urethritis  was  particularly  mild  and  of  short 
duration.  It  also  shows  that  a  tissue  infection  of  the 
glans  is  possible  in  spite  of  the  covering  of  squamous 
epithelium.  Probably  the  inveteracy  of  the  infection 
is  due  to  implication  of  the  sebaceous  glands. 

The  treatment  in  addition  to  circumcision  consists 
of  antiseptic  baths  and  dusting  powders  such  as  bis- 
muth, zinc,  calomel,  and  boric  acid,  with  applications 
several  times  each  day  of  moderately  strong  silver 
solutions  until  the  gonococcus  has  been  eliminated. 


CHAPTER    XI 

GONOCOCCAL   PROSTATITIS 

In  most,  if  not  all  cases  of  posterior  urethritis,  the 
ducts  of  the  prostate  gland  are  more  or  less  included 
in  the  area  of  inflammatory  reaction  ;  but  unless  the 
gonococcus  spreads  along  the  ducts  into  the  substance 
of  the  gland,  a  true  prostatitis  cannot  be  said  to  be 
present.  This,  however,  does  occur  in  a  considerable 
number  of  cases  which  different  authorities  variously 
estimate.  The  published  figures  differ  so  widely  that 
little  object  is  to  be  served  by  quoting  them.  The 
disagreement  is  due  to  the  different  methods  adopted 
in  examining,  and  the  amount  of  inflammatory  in- 
volvement of  the  gland  considered  necessary  before  it 
could  be  classified  as  a  prostatitis. 

The  main  importance  of  the  question  centres  in  the 
fact  that  in  a  large  percentage  of  the  chronic  cases  of 
gonococcus  infection  (60  per  cent  to  90  per  cent), 
examination  will  reveal  a  prostatitis  as  a  source  of 
continued  infection.  As  the  prostate  is  a  gland  which 
plays  a  prominent  role  in  general  metabolism  as  well 
as  in  sexual  life,  and  as  gonorrhoea  is  the  disease  to 
which  it  is  most  liable  at  least  in  early  adult  life,  no 
excuse  is  needed  for  giving  considerable  space  to  its 
consideration. 

Anatomy  of  the  prostate. ^The  prostate,  in  size 
and  shape,  is  comparable  to  a  chestnut ;  to  be  geo- 
metrically exact,  it  is  an  oblate  conoid.     The  base  is 

184 


GONOCOCCAL   PROSTATITIS 


185 


directed  upward  in  contact  with  the  bladder,  and 
the  apex  rests  on  the  triangular  ligament.  The 
greatest  diameter  is  the  transverse  near  its  base,  where 
it  measures  1|  inches  (36  millimetres).  The  vertical 
averages  Ij  inches  (30  millimetres),  and  the  antero- 
posterior I  inch  (18  millimetres).  The  normal  gland 
weighs  from  16  to  24  grammes. 


Fig.  54. 

Showing  section  (much  magnified)  of  normal  prostate  of  a  subject  aged 
nineteen  years^  made  through  middle  of  verumontanum  :  1,  urethra  ;  2, 
verumontaoum  ;  3^  sinus  pocularis  ;  4,  ejaculatory  ducts  ;  5,  prostatic  glands. 
(Taylor.) 

The  posterior  surface  is  pierced  obliquely  in  the 
middle  line  above  by  the  tAvo  ejaculatory  ducts  lying 
side  by  side.  Where  these  enter  the  gland  there  is 
a  notch  which  extends  downwards  as  a  median  groove 
separating  the  gland  into  two  lateral  lobes.  The 
lateral  lobes  meet  in  front  of  the  urethra,  which  is 
enclosed  in  the  substance  of  the  gland.  The  portion 
of  the  organ  above  the  ejaculatory  ducts,  and  lying 
between  them  and  the  urethra  in  front  and  the  bladder 


186    GONORRHCEA  &  ITS  COMPLICATIONS 

above,  is  spoken  of  as  the  middle  lobe.  The  posterior 
surface  is  separated  from  the  rectum  only  by  cellular 
tissue. 

Structure. — The  prostate  possesses  a  dense  fibro- 
muscular  capsule,  arising  from  which  a  median  and 
other  septa  divide  the  gland  into  about  thirty  lobules. 
Bundles  of  unstriped  muscle  follow  the  connective 


y- 


Fig.    55. 


Showing  prostate  of  a  man  in  which  senile  changes  are  beginning  to 
develop.  This  section  was  made  through  the  posterior  portion  of  the  pros- 
tate. Here  the  ducts  run  forward^  and  they  therefore  appear  in  cross- 
section  in  the  drawing.  The  lobulation  apparent  in  the  prostate  of  the 
young  subject  (see  Fig.  54)  is  no  longer  distinct,  owing  to  the  development 
of  fibrous  and  muscular  tissue.  Voluntary  muscle-fibres  are  prominently 
developed  on  the  superior  surface  of  the  organ.  In  the  verumontanum  the  left 
ejaculatory  duct  is  seen  opening  centrally  into  the  prostatic  sinus.  The  right 
ejaculatory  duct  shows  as  yet  no  communication  with  the  prostatic  sinus,  but 
opens  at  a  point  further  forward  ;  (much  magnified).     (Taylor.) 

tissue  framework ;    in  fact,  they  constitute  the  main 
bulk  of  the  stroma. 

The  spongy  glandular  substance  consists  of  fifteen 
to  thirty  tubular  alveoli,  each  opening  through  its 
own  duct  direct  into  the  urethra.     The  epithelium  is 


GONOCOCCAL   PROSTATITIS  187 

cylindrical,  and  there  are  two  layers  but  no  basement 
membrane,  the  epithelial  cells  resting  directly  on  the 
musculo-fibrous  tissue.  Islands  of  lymphoid  tissue 
are  sometimes  found.  The  prostate  contains  a  com- 
phcated  system  of  dehcate  nerve  fibres,  gangHon  cells, 
and  special  nerve  endings. 

Physiology  of  the  prostate.— The  prostate  is  an  essen- 
tial component  of  the  sexual  system  ;    but  not  only 
is  its  external  secretion  a  vital  element  of  the  seminal 
fluid,  the  prostate  also  furnishes  an  internal  secretion 
which,  in  addition  to  governing  the  activity  of  the 
testicles,   influences   the   general   metabolism   of  the 
body.     The  gland  only  reaches  its  full  growth  after 
puberty.       Castration    of    the    child    prevents    the 
development    of   the    prostate.      Castration    in    the 
adult  is  followed  by  atrophy,  but  the  actual  power 
of  coition  is  not  lost  for  some  years,  which  would  seem 
to  indicate  that  the  internal  secretion  of  the  prostate 
is  the  dominating  factor  in  sexual  life. 

The  experiments  of  Serallach  and  Parez,  conducted 
at  Barcelona  on  dogs,  have  afforded  interesting  re- 
sults.   They  found  that  removal  of  the  prostate  was 
followed  by  atrophy  of  the  testicles  and  disappear- 
ance of  spermatozoa  from  the  semen.     If,  however, 
the  animal  was  given  a  glycerine  extract  of  the  pros- 
tate by  the  mouth,  or  a  portion  of  the  gland  was 
grafted    subcutaneously,    the    degenerative    changes 
were  averted.    The  effect  of  the  internal  secretion  on 
the  general  metabohsm  is  illustrated  by  another  ex- 
periment of  the  same  observers.    Twin  pups,  as  nearly 
as  possible  alike,  were  chosen  when  sixty  days  old.   To 
one  was  given  daily  doses  of  the  prostate  extract, 
while   the   other   was   retained   as   a   control.     Five 
weeks  later  a  testicle  was  removed  from  each,  and 
no  examination  the  organ  of  the  puppy  which  had 


188    GONORRHCEA  k  ITS  COMPLICATIONS 

been  fed  on  prostate  was  found  to  be  in  a  much 
more  advanced  stage  of  development  than  that  of  the 
control  animal.  It  was  also  noted  that  the  puppy 
which  was  prostate  fed  was  much  thinner,  more 
active,  inquisitive,  intelligent,  and  excitable  than  the 
other. 

Congenital  abnormalities  of  the  prostate  have  been 
noted  as  part  of  a  general  or  partial  maldevelopment 
of  the  sexual  system.  Fuller  reports  the  case  of  an 
adult  in  whom  the  prostate  was  entirely  absent.  He 
was  capable  of  indulging  in  coitus,  but  spermatozoa 
were  absent  from  the  seminal  fluid. 

Characters  of  the  external  secretion  of  the  prostate. — 
The  prostatic  secretion  is  a  thin,  cloudy  albuminous 
fluid  with  a  characteristic  odour.  It  contains  no 
mucus.  In  reaction  it  is  in  most  cases  either  alka- 
line or  neutral.  In  a  small  percentage  of  cases  it  is 
faintly  acid.  Under  the  microscope  the  most  striking 
feature  is  the  presence  of  lecithin  granules  in  various 
forms.  These  readily  absorb  anilin  stains.  Other 
granules  are  amyloid,  "  corpora  amylacea  "  (Plate  IX), 
staining  blue  with  iodine  and  sulphuric  acid.  Epi- 
thelial cells  are  also  noticed,  and  a  varying  but 
small  number  of  leucocytes  may  be  present. 

The  basic  element  of  the  Bottcher  or  spermatic 
crystals  (Fig.  56)  found  in  the  semen  is  contributed 
by  the  prostatic  secretion.  The  crystals  are  formed  by 
the  combination  of  this  base  with  phosphoric  acid 
obtained  from  other  constituents  of  the  spermatic 
fluid.  The  expressed  secretion  of  the  prostate  will 
not  therefore  show  any  spermatic  crystals  unless 
some  ammonium  phosphate  solution  be  added.  For 
the  purpose  of  demonstrating  these  crystals,  a  drop 
of  prostatic  secretion  is  mixed  with  a  drop  of 
1   per  cent  solution  of  ammonium   phosphate   and 


PLATE  IX. 


Amyloid  Bodies  in  the  Prostatic  Tubules 
Shown  on  Transverse  Section.      [Taylor.] 


GONOCOCCAL    PROSTATITIS  189 

slowly  dried  under  a  cover  glass.  After  a  time  large 
numbers  of  the  needle  or  whetstone  crystals  will  be 
seen.    This  is  a  reliable  test  for  prostatic  secretion. 

That  each  duct  and  tubule  of  the  gland,  hned  as 
they  are  with  a  susceptible  epithelium,  is  not  attacked 
by  the  gonococcus  in  every  case  of  posterior  urethritis 
probably  depends  on  some  restraining  influence  in- 
herent in  the  prostatic  secretion.  Bierhoff  ascribes 
this  property  to  the  alkaline  reaction  of  the  secretion, 


Fig.    56. 
Bottcher's  sperma-crystals.     (Taylor.) 

in  which  case  the  glands  whose  secretion  showed  pro- 
nounced alkalinity  would  be  those  which  escaped 
infection ;  but  Bierhoff  states  that  the  secretion 
even  of  infected  glands  is  alkaline,  and  that  on  this 
account  he  failed  in  his  attempts  to  grow  the  gono- 
coccus from  prostatic  discharge.  Waelsch  suggests 
that  the  known  antiseptic  power  of  lecithin  may  be 
exercised  by  the  granules.  As  a  result  of  inflamma- 
tion the  power  of  lecithin  production  is  lost  by  the 
secreting  cells,  and  it  is  true  that  a  small  inflam- 
matory zone  precedes  the  growth  of  the  gonococcus 
along  the  ducts. 


190    GONORRHCEA  &  ITS  COMPLICATIONS 

Method  of  examining  the  prostate. — Much  informa- 
tion regarding  the  state  of  the  prostate  is  afforded  by 
actual  palpation.  The  most  suitable  position  in 
which  to  place  the  patient  is  to  have  him  kneeling  on 
a  chair  with  his  arms  resting  on  its  back.  In  this 
position,  if  the  bladder  is  distended,  good  access  can 
be  had  to  the  prostate  and  the  seminal  vesicles.  With 
the  gloved  finger  well  lubricated,  a  systematic  ex- 
amination of  the  gland  should  be  made.  In  the 
middle  line  the  course  of  the  prostatic  urethra  should 
be  followed  and  tenderness  or  inequalities  in  its  sur- 
face noted.  Each  lobe  in  turn  should  then  be  ex- 
plored. The  two  halves  should  be  compared  in  size 
and  sensitiveness.  Any  area  of  tenderness  or  swelling, 
or  any  alteration  in  consistence  either  hardening  or 
softening,  should  be  located.  The  condition  of  the 
rectum  and  of  the  perineum  should  also  be  investi- 
gated. 

Before  the  examination  is  undertaken,  the  patient 
should  pass  a  small  quantity  of  urine  into  a  glass  to 
wash  out  the  urethra,  or  preferably  the  anterior 
urethra  should  be  irrigated,  and  thereafter  the  patient 
should  pass  one  or  two  ounces  of  urine.  After  a  care- 
ful scrutiny  of  the  condition  of  the  prostate  b}^  the 
finger  in  the  rectum,  the  gland  should  be  gently  but 
thoroughly  massaged,  each  lateral  lobe  being  stroked 
towards  the  middle  line  to  express  the  secretion  into 
the  urethra.  Some  of  this  secretion  may  escape 
along  the  urethra,  when  it  should  be  collected  for 
microscopical  examination.  It  may  be  allowed  to 
drop  directly  on  to  one  end  of  a  slide,  on  which  it 
should  be  spread  as  in  making  a  blood  smear. 

Upon  completion  of  this  operation,  the  patient 
again  passes  a  small  quantity  of  urine,  which  will 
carry  with  it  the  expressed  products  of  the  prostate. 


GONOCOCCAL   PROSTATITIS  191 

The  bladder  is  then  emptied  into  a  fresh  glass  vessel, 
and  the  whole  tract,  bladder  included,  is  thoroughly 
washed  out  with  a  weak  permanganate  or  silver 
nitrate  solution.  The  urine  containing  the  prostatic 
secretion  should  be  filtered  or  centrifugalised  and  the 
deposit  examined  microscopically. 


CLASSIFICATION  OF  GONOCOCCAL  PROSTATITIS 

Gonococcal  prostatitis  may  be  acute  or  chronic. 
As  regards  the  acute  forms  nearly  all  writers,  es- 
pecially in  Germany  and  America,  adopt  the  classi- 
fication originally  proposed  by  Segond.  They  speak 
of  {a)  catarrhal,  (b)  follicular,  and  (c)  parenchymatous 
prostatitis. 

In  the  catarrhal  type  the  inflammatory  reaction  is 
described  as  being  confined  to  the  epithelium  of  the 
ducts  and  tubules.  Gonococci  spread  along  the 
epithelial  surface,  but  do  not  penetrate  into  the 
tissues. 

The  follicular  type  results  from  a  case  of  catarrhal 
prostatitis,  in  which  instead  of  subsiding  the  process 
increases  in  intensity,  and  one  or  more  of  the  ducts 
become  occluded  with  the  formation  of  small  pseudo- 
abscesses.  The  stoppage  in  the  duct  may  be  over- 
come by  the  increasing  pressure  behind  it,  and,  the 
cyst  discharging  its  contents  into  the  urethra  or  other- 
wise, resolution  and  absorption  may  take  place. 

The  parenchymatous  variety  is  a  further  stage  of  the 
acute  inflammatory  process.  The  inflammation  ex- 
tends from  the  epithelium  deeply  into  the  tissues  of 
the  organ.  Abscess  formation  is  common  in  this 
type. 

I  have  considerable  difficulty  in  accepting  this 
classification.     It  seems  to  me  to  fail  in  the  purpose 


192    GONORRHCEA  &  ITS  COMPLICATIONS 

for  which  all  classification  is  intended.  It  does  not 
simplify  the  teaching  of  the  subject ;  it  obscures  the 
clinical  picture,  and  gives  a  false  perspective  to 
some  details.  The  expression  "  catarrhal  prosta- 
titis "  is  inaccurate  and  misleading.  The  prostatic 
tubules  have  no  mucous  membrane  properly  so  called, 
and  secrete  no  mucus,  and  it  is  impossible  to  imagine 
the  gonococci  not  penetrating  into  and  beneath  the 
epithelium.  The  term  follicular  prostatitis  suggests 
invasion  of  the  gland  follicles  in  contradistinction  to 
localisation  of  the  infection  in  the  ducts.  Why  it 
should  be  adopted  as  a  designation  for  cystic  abscess 
is  incomprehensible.  The  occlusion  of  a  duct  is  not 
characteristic  of  a  distinct  type  of  prostatitis,  but  is 
a  complication  occurring  in  the  course  of  an  ordinary 
infection,  and  should  be  described  as  such.  The 
parenchymatous  type  includes  hyperacute  cases,  in 
which  there  is  considerable  risk  of  abscess  formation. 

An  attempt  to  classify  disease  conditions  of  an 
organ  such  as  the  prostate  may  be  governed  either 
by  differing  pathological  characteristics,  distinctive 
clinical  symptoms,  or  by  anatomical  considerations. 
As  a  rule,  when  the  pathological  conditions  vary, 
a  different  train  of  clinical  symptoms  is  induced,  so 
that  from  both  of  these  standpoints  classification  is 
reinforced.  In  prostatitis  we  find  no  essential  differ- 
ence in  the  pathological  processes  at  work  other  than 
one  of  acuteness,  and  this  is  mirrored  by  the  clinical 
symptoms. 

It  is  universally  recognised  that  there  may  be  an 
acute,  subacute,  or  chronic  inflammation,  and  that  the 
chronic  condition  may  follow  from  the  acute  or  suba  cute . 
The  not  uncommon  assertion  that  a  case  may  be  of  the 
chronic  type  from  its  inception  is  surely  in  the  case  of 
gonococcus  infection  a  misuse   of  terms.     What  is 


GONOCOCCAL   PROSTATITIS  193 

doubtless  meant  is  that  a  mild  subacute  case  may 
ultimately  become  chronic.  There  is  no  special 
feature  of  chronic  as  opposed  to  mild  subacute  gono- 
coccal inflammation  other  than  the  time  limit  pro- 
duces. 

In  describing  urethritis  everyone  adopts  the  group- 
ing into  three  principal  types — subacute,  acute,  and 
hyperacute.  Pseudo-abscesses  and  abscesses  occur, 
but  they  are  incidents  and  not  characteristics  ;  and 
although  relatively  more  common  and  important  in 
connection  with  prostatitis,  they  are  not  sufficiently 
so  to  form  a  basis  for  classification  at  the  expense 
of  the  more  obvious  and  reasonable  subdivision 
according  to  the  acuteness  of  the  inflammation. 

The  "  subacute "  group  would  include  all  cases 
where  the  infection  was  comparatively  superficial 
(epithelium  and  immediately  underlying  tissue)  and 
giving  rise  to  mild  symptoms.  The  "  acute  "  designa- 
tion would  be  descriptive  of  a  more  severe  inflam- 
matory reaction  in  which  the  objective  and  subjective 
symptoms  indicated  an  inflammatory  hyperasmia  and 
infiltration  of  a  lobule,  lobe,  or  of  the  whole  gland, 
signifying  penetration  of  the  gonococcus  into  the 
stroma.  The  previous  sentence  suggests  an  anatomi- 
cal subdivision,  lobular,  lobar,  and  glandular  ;  but 
clinical  experience  does  not  meantime  warrant  its 
general  adoption,  although  in  individual  cases  the 
terms  lobular  and  lobar  could  occasionally  be  used 
with  descriptive  accuracy.  As  a  rule  the  whole  gland 
is  more  or  less  involved,  although  at  any  given  time 
different  lobules  may  have  arrived  at  different  stages 
of  the  inflammatory  process,  as  evidenced  by  varia- 
tions in  the  consistence  of  the  gland  at  separate  points 
of  its  surface.  The  term  hyperacute  would  describe 
all  those  cases  in  which  rapid  oedematous  swelling 


194    GONORRHCEA  &  ITS  COMPLICATIONS 

of  the  gland  gave  rise  to  distressing  symptoms.  The 
lobular  pseudo-abscess  should  be  noted  as  being 
liable  to  occur  in  the  subacute  and  acute  types,  and 
abscess  formation  in  the  hyperacute.  Confining  one- 
self to  this  classification  enables  the  disease  process  to 
be  described  with  faithful  adherence  to  the  known 
tendencies  of  gonococcal  activity  as  well  as  to  the 
usual  clinical  progress  of  the  disease. 

Acute  gonococcal  prostatitis. — Spreading  along  the 
ducts,  the  gonococcus,  in  a  moderately  acute  case, 
produces  the  ordinary  inflammatory  reaction.  The 
epithelial  cells  are  loosened  and  shed.  The  secreting 
cells  are  altered  in  formation  and  function.  They 
swell  and  become  incapable  of  secreting  the  finely- 
divided  emulsion  of  lecithin  granules.  Polynuclear 
leucocytes  are  extruded  in  numbers,  and  round-celled 
infiltration  occurs  in  the  subepithelial  tissue.  A  sero- 
purulent  secretion  occupies  the  lumen  of  the  tubules, 
whence  it  is  poured  into  the  posterior  urethra.  In 
a  short  time  the  discharge  has  the  appearance  of 
yellow  pus.  The  posterior  ru'cthra,  as  seen  through 
the  urethroscope,  has  been  described  by  Socin  and 
Burckhards.  The  mucous  membrane  was  swollen, 
deep  blue-red  in  colour,  and  bled  easily.  The  crista 
urethrse  was  so  inflamed  that  it  filled  the  whole 
lumen  of  the  canal.  Pus  oozed  from  the  mouths  of  the 
prostatic  ducts. 

On  palpation  through  the  rectum  evidence  of  the 
inflammation  of  the  gland  may  be  perceived  ;  on  the 
other  hand,  there  may  be  little  indication  of  anything 
abnormal  other  than  would  be  obtained  in  a  posterior 
urethritis  without  prostatitis.  The  difference  of 
sensitiveness  found  jn  the  posterior  urethra  of 
different  individuals  has  already  been  referred  to,  and 
the  same  peculiarity  is  found  in  regard  to  the  pros- 


GONOCOCCAL   PROSTATITIS  195 

tate,  some  being  much  more  sensitive  than  others. 
In  all  cases  if  the  inflammatory  process  has  extended 
so  far  along  the  tubules  as  to  approach  the  posterior 
surface  of  the  gland,  hypersensitive  areas  will  be 
found,  and  deep  pressure  will  in  most  cases  elicit 
tenderness  ;  but  there  may  be  considerable  involve- 
ment of  that  portion  of  the  gland  surrounding  the 
urethra  without  any  diagnostic  evidence  being  pro- 
curable by  means  of  palpation.  The  occurrence  of 
a  lobular  cyst  (pseudo-abscess)  through  occlusion  of 
a  duct  may  be  felt  as  a  small,  very  sensitive  protu- 
berance the  size  of  a  split  pea  on  the  otherwise  smooth 
surface  of  the  lobe.  If  only  a  thin  layer  of  tissue 
separates  the  cyst  from  the  rectum,  softening  may 
be  made  out.  Should  this  pseudo-abscess  discharge, 
as  usually  happens,  into  the  urethra,  the  nodule  will 
be  replaced  by  a  depression.  If  the  contents  do 
not  escape  in  this  way,  absorption  may  ultimately 
take  place.  When  the  infection  extends  more  quickly 
and  more  deeply  into  one  lobe  than  into  another, 
variations  in  consistence  may  be  felt.  In  the  most 
severe  cases,  a  lobe  or  the  whole  gland  will  be  enlarged, 
hot  and  tender.  Engorged  blood-vessels  will  be  felt 
coursing  on  the  tense  elastic  surface  of  the  organ, 
and  a  feeling  of  pulsation  may  be  conveyed  to  the 
examining  finger. 

The  inflammation  usually  begins  to  subside  in  from 
five  to  ten  days,  and  complete  resolution  may  even- 
tuate ;  but  in  many  cases  a  chronic  infection  re- 
mains. On  the  other  hand,  the  process  may  increase 
in  intensity,  and  abscess  formation  may  then  be 
anticipated. 

Subjective  symptoms. — In  subacute  and  moderately 
acute  cases  the  condition  cannot  be  differentiated  by 
the    subjective    symptoms    from    the    accompanying 


196    GONORRHCEA  &  ITS  COMPLICATIONS 

acute  posterior  urethritis.  There  is  an  actual  in- 
crease in  the  amount  of  discharge,  but  this  is  only 
evident  on  close  and  continued  examination  of  the 
urine.  Difficulties  in  urination  and  defecation  are 
increased ;  but  as  these  symptoms  are  all  com- 
parative, they  have  little  diagnostic  value.  In  severe 
cases,  however,  there  is  complaint  of  a  foreign  body 
in  the  rectum  causing  continuous  urinary  and  rectal 
tenesmus.  Pain  is  always  very  considerable,  and 
radiates  from  the  perineum  to  the  glans,  down  the 
thighs,  and  across  and  up  the  back. 

The  diagnosis  is  dependent  on  the  examination  of 
the  prostatic  secretion  and  on  rectal  palpation,  but 
some  assistance  is  obtained  from  the  three-glass  urine 
test.  The  first  glass  as  usual  contains  the  pus  carried 
from  the  whole  urethra.  The  second  shows  the 
condition  of  the  urine  in  the  bladder  with  its  regurgi- 
tated pus  from  the  posterior  urethra.  The  third 
shows  the  same  as  the  second  plus  such  discharge  as 
may  be  squeezed  from  the  prostate  in  the  final  stages 
of  micturition.  If  the  prostate  be  massaged  in  an 
interval  between  the  passage  of  glass  two  and  glass 
three,  there  is  much  more  c'ertainty  of  the  third  glass 
containing  prostatic  contents.  The  first  and  the 
third  glasses  should  show  greater  concentration  of  pus 
than  the  second.  During  the  manipulation  of  the 
prostate  some  of  its  discharge  may  escape  from  the 
meatus,  and  this  should  be  caught  on  a  glass  slide 
for  examination.  The  contents  of  the  third  glass 
should  be  filtered  or  centrifugalised  and  the  deposit 
microscopically  examined. 

More  exact  results  can  be  obtained  by  washing  out 
the  urethra  and  bladder  with  boric  solution,  ulti- 
mately leaving  an  ounce  or  so  of  the  solution  in  the 
bladder.     The  prostate  is  then  massaged,  and  finally 


GONOCOCCAL    PROSTATITIS  197 

the  retained  solution  is  expelled,  carrying  in  front  of 
it  the  prostatic  discharge.  This  is  removed  by  the 
centrifuge  and  examined.  This  procedure  as  a  means 
of  diagnosis  will,  however,  be  contra-indicated  in 
most  cases,  and  even  massage  of  the  prostate  should 
only  be  undertaken  with  caution,  as  it  is  liable  to 
cause  an  extension  of  the  disease  in  acute  conditions. 
It  is  possible  that  if  done  jerkily  or  roughly  trau- 
matism might  be  caused  to  the  hypersemic  and  tender 
tissue,  and  there  is  the  further  risk  of  cocci  being 
sucked  into  unaffected  ducts  or  more  deeply  into  the 
tubules.  If  massage  is  practised,  care  must  be  taken 
that  the  pressure  is  sufficiently  gentle  and  equable. 

The  secretion  of  the  infected  prostate  shows  character- 
istic macroscopic  as  well  as  microscopic  changes.  The 
normal  secretion  is  an  opalescent,  slightly  milky 
emulsion,  neither  watery  nor  yet  of  tenacious  con- 
sistence. The  secretion  from  the  diseased  gland  is 
a  mixture  of  serous  exudation  and  pus.  It  is  always 
alkaline  to  litmus.  It  has  a  dirty  grey  colour,  and 
has  not  the  character  of  a  finely  divided  emulsion,  but 
of  a  suspension  of  irregular  particles. 

Minute  particles,  flakes,  or  comma-shaped  threads 
are  expressed  from  the  ducts  with  the  discharge  and 
found  in  the  prostatic  urine  glass.  They  are  com- 
posed of  pus  and  epithelial  cells  cemented  together 
by  serous  exudate. 

Under  the  microscope  are  seen  numerous  polynu- 
clear  leucocytes,  some  of  them  containing  lecithin 
granules,  for  which  they  seem  to  have  an  affinity, 
and  also  epithelial  cells  sometimes  showing  the  two- 
layer  arrangement.  Lecithin  granules  are  not  en- 
tirely absent,  but  are  much  scantier  than  in  the 
normal  secretion.  Only  rarely  are  amyloid  bodies 
noticed.    The  pus  cells  in  the  early  stages  are  mostly 


198    GOIS^ORRHCEA  &  ITS  COMPLICATIONS 

polynuclear.  Some  writers  maintain  that  a  high 
proportion  of  eosinophile  cells  is  of  diagnostic  im- 
portance. Both  intracellular  and  extracellular  gono- 
cocci  are  found,  but  they  are  not  so  numerous  as  in 
the  urethral  secretion. 

THE    TREATMENT   OF   ACUTE    PROSTATITIS 

In  the  acute  stages  it  is  necessary  to  keep  the 
patient  in  bed.  In  many  cases  no  persuasion  is  needed, 
as  he  is  unable  to  move  about.  Careful  dieting  and 
regulation  of  the  bowels  are  important.  Hot  sitz 
baths  two  or  three  times  daily,  lasting  six  to  eight 
minutes,   followed  by  hot  fomentations  to  the  per- 


FiG.  57. 
Rectal  tube  for  prostatic  hydrotherapy. 

ineum,  will  be  found  soothing.  Even  more  effective 
is  irrigation  through  a  double-channel  rectal  tube 
(Fig.  57),  by  means  of  which  a  stream  of  hot  water  is 
made  to  flow  over  the  posterior  aspect  of  the  pros- 
tate several  times  during  the  day.  Care  must  be 
taken  by  external  cleansing  to  obviate  the  risk  of 
rectal  infection.  Following  this  douche  a  supposi- 
tory, containing  ^  to  1  grain  of  opium  and  J  to  | 
grain  of  belladonna,  may  be  inserted  if  there  is  great 
discomfort.  A  solution  of  antipyrine  injected  into 
the  rectum  is  also  helpful  in  relieving  pain  and  re- 
ducing temperature.  In  the  earlier  stage  the  use  of 
cold  instead  of  hot  water  may  have  a  restraining  influ- 
ence on  the  spread  of  the  inflammation,  but  the  effect 
must  be  carefully  watched.  Leeches  (ten  to  twelve) 
applied  to  the  perineum  are  often  of  distinct  value. 


GONOCOCCAL   PROSTATITIS  199 

If  there  be  retention  of  urine  which  is  unreheved 
by  hot  sitz  baths  and  fomentations,  a  catheter,  pre- 
ferably a  soft  one,  may  have  to  be  passed.  Whether 
a  self -retaining  catheter  should  be  left  in  the  bladder 
must  be  decided  on  the  merits  of  the  particular  case. 
Should  one  be  left  in  situ  and  increased  irritation 
result,  it  must  be  withdrawn.  If  the  passage  of  the 
catheter  ruptures  an  abscess  there  will,  of  course, 
be  no  need  to  consider  the  question  of  a  retained 
catheter.  It  will  seldom  happen  that  catheteriza- 
tion by  some  form  of  instrument  is  found  to  be 
impossible,  but  should  such  be  the  case  the  alterna- 
tives are  puncture  of  the  bladder  through  the 
abdominal  wall,  or  perineal  section  with  bladder 
drainage.  It  is  sometimes  found  that  after  relief  has 
been  obtained  by  bladder  puncture  a  catheter  can 
pass  the  obstruction  or  even  that  this  is  unnecessary 
as  spontaneous  urination  may  be  re-established. 

During  the  height  of  the  inflammation  all  urethral 
treatment  must  be  withheld.  In  picked  cases  it  may 
be  possible  to  continue  Janet  irrigations  with  weak 
permanganate  or  silver  nitrate  solution,  but  when 
the  symptoms  are  at  all  acute  it  is  safer  to  defer  any 
local  treatment  of  the  urethra. 

Balsamics  have  their  limited  field  of  usefulness, 
and  urinary  antiseptics  may  be  continued  with  som.e 
advantage. 

PROSTATIC   ABSCESS 

Abscess  formation  is  an  important  but  fortunately 
a  comparatively  uncommon  associate  of  acute  and 
hyperacute  prostatitis.  At  any  moment  as  long  as 
the  gonococcus  infection  is  present  an  acute  con- 
dition may  be  precipitated  by  traumatism  or  any  of 
the  exciting  causes  of  gonorrhoeal  activity. 


200    GONORRHCEA  &  ITS  COMPLICATIONS 

Abscess  may  be  preceded  by  a  lobular  cyst  (pseudo- 
abscess).  When  emptying  into  the  urethra  is  delayed, 
destruction  of  the  cyst  walls  converts  the  condition 
into  one  of  true  abscess.  In  a  hyperacute  prostatitis 
a  small  focus  of  pus  forming  in  the  stroma  may  by 
itself  or  by  coalescing  with  other  similar  pockets  go 
on  to  the  production  of  an  abscess. 

Symjdtoms. — The  patient's  temperature  chart  is 
not,  as  a  rule,  noticeably  affected  by  the  occurrence 
of  a  prostatitis  unless  an  abscess  develops.  But 
in  that  case,  following  perhaps  on  a  rigor,  the  tem- 
perature jumps  to  103°  or  104°  F.,  after  which  it 
oscillates  between  100°  and  102°  F.  Other  indica- 
tions of  septic  absorption  are  headache,  dry  tongue, 
thirst,  and  profuse  perspiration. 

Fever  is  not  an  invariable  accompaniment  of 
abscesses.  Henrichson  reports  elevation  of  tempera- 
ture in  only  ten  out  of  thirty-four  cases.  When  the 
abscess  bursts  spontaneously  into  the  urethra,  as  it 
commonly  does,  the  temperature  falls — to  rise  again 
— if,  on  account  of  insufficient  drainage,  the  pus 
reaccumulates. 

The  most  urgent  complaint  on  the  patient's  part 
is  of  throbbing  pain  from  a  foreign  body  in  the 
rectum.  The  pain  radiates  in  all  directions,  especially 
on  movement.  He  therefore  adopts  the  position 
most  likely  to  relieve  perineal  tension,  and  lies  on  his 
back  with  the  knees  draw^n  up  and  resolutely  objects 
to  being  moved. 

Owing  to  the  swollen  prostate  impinging  on  the 
urethra,  the  urine  is  discharged  in  a  small  stream,  or 
there  may  be  complete  retention  necessitating  the 
use  of  the  catheter.  Not  infrequently  the  passage 
of  the  instrument  ruptures  the  abscess  and  pus  wells 
out.     The  presence  of  the  tender  mass  in  the  pelvis 


GONOCOCCAL   PROSTATITIS 


201 


interferes  also  with  bowel  movement,  which  the 
patient  dreads  on  account  of  the  pain.  There  may 
be  little  or  no  m^ethral  discharge.  This  may  be  due 
to  the  urethritis  having  completed  its  acute  stage,  or 
it  may  be  comparable  to  the  temporary  suppression 
sometimes  met  with  in  epididymitis,  in  which  case 
a  recurrence  of  the  discharge  may  be  expected  in 
from  five  to  seven  days. 

On  palpation  there  is  felt  projecting  into  the 
rectum  one  or  both  lobes  of  the  prostate,  tense,  hot, 
tender,  and,  if  in  the  early  stage,  hard.  Softening  will 
be  in  evidence  later,  and  ultimately  fluctuation  will 
complete  the  diagnosis. 

In  the  great  majority  of  cases  the  abscess  dis- 
charges into  the  urethra  in  from  five  to  twelve  days. 
There  is  a  sudden  violent  pain  followed  by  the  appear- 
ance at  the  meatus  of  a  quantity  of  blood-tinged  pus. 
Rupture  may  be  precipitated  by  palpation  of  the 
prostate  or  by  the  passage  of  a  catheter. 

In  addition  to  the  urethral  path  there  are  many 
directions  in  which  a  prostatic  abscess  may  seek  an 
exit  if  not  relieved  by  incision.  Segond  collected  104 
cases  which  discharged  as  follows  : — 

1.  Into  the  urethra   ....      64  cases 
rectum    .  .  .  .      43     ,, 


2 

3.  ,,     ,,      perineum 

4.  ,,     ,,      ischio-rectal  fossa 

5.  ,,     ,,      inguinal  region 

6.  ,,     ,,      Through  the  obturator  for 

amen 

7.  Through  the  umbilicus  . 

8.  ,,  ,,    sciatic  notch 

9.  Into  the  peritoneum 

10.  ,,     ,,      perivesical  cellular  tissue 

11.  At  the  angle  of  the  false  ribs  . 


15 


1  case 
each 


202    GONORRHCEA  &  ITS  COMPLICATIONS 

Rupture  in  two  directions  may  occur  simul- 
taneously, and  a  urinary  fistula  may  be  produced. 

Under  the  guidance  of  modern  surgery  such  results 
would  seldom  be  allowed  to  happen,  and  in  any  case 
the  relative  proportions  in  the  above  table  are  mis- 
leading, as  many  instances  of  rupture  into  the  urethra 
are  unrecognised.  Guiteras,  although  unable  to  give 
definite  statistics,  states  as  his  opinion  that  in  95 
per  cent  of  cases  the  abscess  finds  its  way  into  the 
urethra. 

General  pyaemia  is  rare  as  a  result  of  prostatic 
abscess,  but  it  may  arise  from  the  loosening  of  clots 
from  a  thrombosed  vein  on  the  surface  of  the  gland. 
The  gonococcus  is  frequently  present  in  pure  culture 
in  the  early  stage,  but  later  admixture  with  other 
organisms  is  the  rule ;  of  these  staphylococci,  strepto- 
cocci, the  colon  bacillus,  and  anaerobic  organisms  are 
the  commonest  invaders. 

The  possibility  of  pre-existing  tubercular  disease  of 
the  prostate  must  not  be  overlooked.  Septic  pneu- 
monia is  a  grave  complication  which  is  sometimes 
encountered. 

Extravasation  of  urine  as  a  result  of  prostatic 
abscess  has  been  reported,  but  it  must  be  uncommon, 
as  the  cavity  quickly  contracts  and  granulation  tissue 
soon  obliterates  the  sac. 

The  cicatricial  scar  may  give  rise  to  deformity  of 
the  parts.  Considerable  loss  of  gland  substance  can 
be  demonstrated  on  palpation,  one  or  both  lobes  being 
much  atrophied.  A  small  chronic  sinus  opening  into 
the  urethra  is  sometimes  a  source  of  continued 
trouble  :  infectivity  can  in  this  way  be  kept  up  for 
several  months. 

Prognosis. — The  onset  of  a  prostatic  abscess  will 
give  rise  to  anxiety  until  it  bursts  or  is  incised  and 


GONOCOCCAL   PROSTATITIS  203 

healing  is  established.  Septic  peri-prostatitis  and 
phlebitis  of  the  prostatic  phlexus  of  veins  are  said 
to  give  rise  to  fatal  complications  in  40  per  cent  of 
the  cases  in  which  they  occur,  but  surgical  interven- 
tion at  the  right  time  should  eliminate  much  of  the 
risk. 

Treatment. — The  surgical  axiom  that  where  pus 
is  the  knife  should  follow,  is  only  applicable  to  a 
small  proportion  of  the  cases  of  prostatic  abscess. 
The  fact  that  the  great  majority  of  prostatic  abscesses 
burst  spontaneously  into  the  urethra  and  heal  there- 
after as  quickly  and  with  much  less  discomfort  to 
the  patient  than  if  they  had  been  incised,  negatives 
surgical  intervention  as  a  routine  procedure. 

Prostatic  abscess  is  comparable  to  abscess  of  the 
tonsil  with  this  difference,  that  opening  into  the 
former  is  a  formidable  operation  and  into  the  latter 
a  very  minor  affair.  Nevertheless  cases  occur  where 
operation  is  advisable,  and  sometimes  where  it  is 
necessary  in  order  to  save  the  gland  from  destruction 
if  not  to  save  the  patient  from  death. 

Operation  being  decided  upon,  by  w^hich  route 
should  the  abscess  be  attacked  ?  It  does  not  solve 
the  difficulty  to  say  that  incision  should  be  made 
where  the  abscess  points,  otherwise  this  would  mean 
the  adoption,  almost  as  a  routine  measure,  of  the 
procedure  advocated  strongly  by  Guiteras,  viz.,  to 
incise  the  abscess  through  the  prostatic  urethral  wall 
after  performing  perineal  urethrotomy.  In  some 
cases  it  might  mean  puncture  through  the  rectum. 
It  would  seldom  suggest  a  direct  perineal  operation 
and  drainage,  and  yet  this  is  the  most  favoured,  as  it 
is  perhaps  the  most  surgically  correct  method. 

The  rectal  is  the  easiest  route  by  which  to  reach 
an    abscess    whose    fluctuating    cavity    can    be    felt 


204    GONORRHCEA  &  ITS  COMPLICATIONS 

through  the  rectal  wall.  Relief  by  puncture  is  not 
unlikely  to  be  followed  by  speedy  reaccumulation  of 
the  pus  ;  incision  of  the  rectal  wall  and  blunt  dis- 
section into  the  abscess  is  therefore  the  procedure 
advocated  by  most  of  the  supporters  of  this  method. 
There  are,  however,  three  obvious  objections  to  this 
operation,  viz.,  the  risk  amounting  almost  to  cer- 
tainty of  gonococcal  infection  of  the  rectal  mucous 
membrane  ;  the  danger  of  rapid  absorption  of  toxine  ; 
and  the  probability  of  introducing  contaminating 
organisms  to  the  abscess  cavity. 

In  operating  through  the  urethra,  a  perineal  ure- 
throtomy is  first  performed  and  the  finger  passed  into 
the  urethral  canal  locates  the  abscess  where  it  points 
in  the  prostatic  urethra.  A  sharp-pointed  curved 
bistoury,  four-fifths  of  whose  blade  is  protected  by 
a  wrapping  of  gauze  or  cotton,  leaving  only  the  point 
free,  is  passed  along  the  finger  and  a  short  incision 
is  made  into  the  abscess.  Great  care  must  be  exer- 
cised to  avoid  cutting  the  external  sphincter,  other- 
wise incontinence  of  urine  will  result.  Guiteras 
remarks  that  frequently  the  abscess  will  be  found  to 
discharge  immediately  on  first  opening  into  the 
posterior  urethra,  in  which  case  no  further  puncture 
will  be  necessary. 

The  consensus  of  opinion  is  distinctly  in  favour  of 
the  direct  opening  into  the  abscess  from  the  perineum 
in  the  great  majority  of  cases  in  which  operation  is 
obligatory.  The  patient  is  placed  in  the  lithotomy 
position,  the  rectum  plugged  with  gauze,  and  if 
possible  a  large  metal  instrument  is  passed  into  the 
bladder  to  indicate  the  position  of  the  urethra.  A 
semicircular  skin  incision  is  made  in  front  of  and 
parallel  with  the  external  sphincter  of  the  rectum. 
The  incision  is  continued  through  the  superficial  fascia, 


GONOCOCCAL   PROSTATITIS  205 

the  perineal  raphe,  and  ischio-rectal  fat,  until  the 
anterior  layer  of  the  perineal  fascia  and  the  trans- 
versus  perinei  muscles  are  reached.  The  muscle  is 
hooked  forward  and  deep  dissection  proceeds,  the 
anterior  rectal  wall  being  pushed  backwards,  and 
the  bulbous  urethra  and  Cowper's  glands  forward. 
Blunt  dissection  will  suffice  to  separate  the  urethra 
from  the  rectal  wall  until  the  prostate  is  reached,  and 
the  abscess  or  abscesses  thoroughly  laid  open  and 
packed.  Complete  closure  of  the  Avound  may  be 
anticipated  in  six  to  eight  weeks. 

Macmunn  recommends  puncture  of  the  prostatic 
urethra  through  the  urethroscope  with  a  specially 
constructed  knife.  In  selected  cases,  with  the  patient 
under  a  general  anaesthetic,  this  measure  might  be 
attempted  by  an  expert  urethroscopist. 


CHRONIC   PROSTATITIS 

The  potentialities  of  the  chronically  diseased  pros- 
tate as  a  focus  for  recurring  infections  both  of  the 
patient  and  his  consort,  and  as  a  disturber  of  the 
health  in  general,  of  the  nerve  balance  and  of  sexual 
effectiveness  in  particular,  have  not  received  their 
due  recognition  from  the  medical  profession.  Over- 
statements of  the  case  against  the  prostate  have 
rightly  received  criticism  ;  but,  after  all  necessary 
allowances  have  been  made  for  possible  exaggeration, 
there  remains  the  fact  that  much  unhappiness  and  ill- 
health  due  to  this  cause  is  untreated  and  unrelieved 
because  the  crucial  lesion  is  not  diagnosed.  \\^ien 
this  question  is  better  understood,  rectal  examina- 
tions will  be  a  hundredfold  more  common  than  they 
are  to-day.  No  consideration  will  deter  either  the 
physician   or  the   patient   when   it   is   realised   what 


206    GONORRHCEA  &  ITS  COMPLICATIONS 

possibilities  of  relief  are  associated  Avith  proper  diagno- 
sis and  treatment  of  the  diseases  of  this  important 
organ.  A  rectal  examination  in  a  genito-urinary  case 
is  not  less  important  than  a  vaginal  examination  in 
a  gynaecological  case. 

Chronic  prostatitis  may  follow  in  the  train  of  any 
of  the  acute  forms  of  prostatitis  and  may  last  for 
years.  Cases  of  chronic  prostatitis  may  be  separated 
into  two  divisions  according  to  whether  the  symptoms 
are  mild  or  severe.  But  the  mild  cases,  after  lying 
quiescent  for  longer  or  shorter  intervals,  are  liable  to 
exacerbations  following  alcoholic  or  sexual  excesses, 
a  debilitated  state  of  the  general  health,  exposure  to 
cold  or  damp,  or  traumatism  such  as  may  occur  from 
the  passage  of  instruments  or  during  horse-riding, 
bicycling,  or  gymnastics. 

Subacute  prostatitis  in  particular  is  likely  to  lapse 
into  the  mild  chronic  condition  which  may  give  little 
or  no  subjective  indication  of  its  presence.  It  is 
usually  the  observation  in  the  urine  ;of  minute  cork- 
screw filaments  or  comma  forms  that  suggests  an 
examination  of  the  prostate,  and  enables  this  type 
of  chronic  prostatitis  to  be  diagnosed.  There  is  fre- 
quently some  degree  of  chronic  posterior  urethritis 
accompanying  the  prostatic  infection,  but  it  may 
be  slight  and  offer  little  symptomatic  proof  of  its 
presence.  Palpation  in  most  cases  will  afford  in- 
formation of  value.  The  examiner  may  gain  an  im- 
pression of  hardness  and  shrinking  of  the  gland 
suggestive  of  atrophic  cirrhosis,  but  in  the  majority 
of  cases  some  area  of  hypertrophy  is  found.  Differ- 
ence in  the  size  of  the  two  lobes  is  very  suspicious. 
The  surface  may  be  either  smooth  or  nodular. 

Other  symptoms  which  would  attract  attention 
to  the  prostate  are  functional  disturbances  of  urina- 


GONOCOCCAL   PROSTATITIS  207 

tion,  e.g.,  feeling  that  the  bladder  had  not  completely 
emptied,  or  delayed  or  inefficient  expulsion  of  the 
last  drops  of  urine  ;  functional  disturbances  of  the 
sexual  powers,  e.g.,  mipotence  with  increased  desire  ; 
spontaneous  discharge  of  prostatic  or  spermatic  fluid 
while  at  stool,  or  spasmodic  leakage  of  prostatic  fluid 
due  to  loss  of  muscular  tone.  Chronic  rheumatic 
pains  are  a  frequent  complaint  in  prostatitis. 

Character  of  the  prostatic  fluid  in  chronic  jjrostatitis. 
— It  is  impossible  to  get  uncontaminated  prostatic 
fluid  for  bacteriological  examination.  The  nearest 
approach  to  an  exact  method  is  to  obtain  the  ex- 
pressed secretion  direct  from  the  prostatic  ducts 
through  a  urethroscope  after  a  cleansing  of  the 
posterior  urethra.  The  usual  procedure,  however,  is 
as  follows  :  The  anterior  urethra  is  washed  out  with 
boric  solution.  The  reservoir  of  the  irrigator  is  raised 
and  the  bladder  is  filled  with  the  solution.  The 
patient  empties  the  bladder  and  the  process  is  repeated 
with  sterile  water,  but  a  small  quantity,  from  one- 
half  to  one  ounce,  is  retained  in  the  bladder.  The 
prostate  is  now  massaged,  and  any  secretion  reaching 
the  external  meatus  is  caught  on  a  slide.  The  patient 
finally  empties  the  bladder  completely,  and  the  ex- 
pelled fluid  is  centrifugalised  or  filtered  and  the  deposit 
examined.  If  the  patient  can  voluntarily  expel  the 
prostatic  secretion  from  the  posterior  urethra  it 
would  be  preferable  to  leave  no  fluid  in  the  bladder, 
but  only  a  trial  in  each  case  can  prove  which  is  the 
better  plan. 

Macroscopically,  appearances  suggestive  of  a  dis- 
eased state  are  usually  evident.  Two  or  three  puru- 
lent casts  of  prostatic  ducts  may  be  seen  floating 
in  the  turbid  solution.  In  addition  to  myriads  of 
fine  m_ucilaginous  filaments  and  flakes  many  minute 


208    GONORRHOEA  &  ITS  COMPLICATIONS 

points  or  larger  fragments  of  curdy  pus  are  seen  in 
suspension.  If  the  contents  of  the  seminal  vesicles 
have  been  expelled  along  with  the  prostatic  secretion 
they  quickly  settle  to  the  bottom  of  the  vessel  and 
appear  like  translucent  sago  grains  or,  as  Waelsch 
says,  chloroform  drops. 

Microscopically,  the  diagnostic  proof  of  disease  is 
the  presence  of  polynuclear  leucocytes  in  consider- 
able quantity.  Many  of  these  cells  will  be  seen  to 
contain  lecithin.  Amyloid  bodies  are  scanty  or 
absent.  Many  desquamated  epithelial  cells  are  pre- 
sent. Gonococci  are  very  difficult  to  find  in  the 
secretion,  as  is  to  be  expected,  but  their  scarcity  in  the 
fluid  does  not  prove  their  absence  from  the  gland.  If 
a  smear  could  be  obtained  direct  from  the  wall  of  an 
infected  lobule  they  would  probably  be  easily  identi- 
fied. If  there  has  been  a  superinfection  other  organ- 
isms will  be  present. 

Sexual  neurasthenia. — As  neurasthenic  symptoms 
are  so  frequently  associated  with  chronic  prostatitis 
they  require  special  consideration.  That  the  neuras- 
thenia is  due  to  the  diseased  state  of  the  prostate  and 
that  the  prostatic  complaints  are  not  symptomatic 
of  the  neurasthenia  is  proved  by  the  fact  that  satis- 
factory treatment  of  the  prostate  cures  the  neuras- 
thenia. It  may  be  suggested  that  treatment  of  any 
sort  applied  to  any  region  of  the  body,  so  long  as  the 
patient's  faith  in  the  method  can  be  sufficiently 
stimulated,  will  relieve  the  neurasthenia.  This  does 
not  apply,  however,  to  this  particular  class  of  neuras- 
thenia. Until  the  prostate  can  discharge  its  normal 
functions,  no  amount  of  suggestion  will  be  of  any 
real  benefit  to  the  case. 

Neurasthenia  is  but  rarely  an  accompaniment  of 
gonococcal   infection   of   any   organ   other   than   the 


GONOCOCCAL    PROSTATITIS  209 

prostate,  therefore  it  is  not  a  toxaemia.  It  is  due 
either  to  interference  with  a  proper  supply  of  the 
internal  secretion  of  the  gland  or  is  dependent  on  a 
chronic  irritation  of  the  complex  nerve  system  of  the 
organ.  In  addition  to  the  symptoms  of  chronic 
prostatitis  the  nervous  disturbances  commonly  pre- 
sent relating  to  the  urinary  system  are  polyuria, 
sudden  imperative  call  to  micturition,  and  a  feeling 
that  the  bladder  is  never  completely  emptied.  Phos- 
phaturia  is  frequently  present,  and  being  mistaken 
for  spermatorrhoea  causes  the  patient  much  mental 
distress. 

The  perverted  nervous  feelings  complained  of  in- 
clude— feeling  of  alternate  heat  and  cold  accompanied 
by  "  clammy  "  sweating  and  particularly  affecting 
the  back  and  limbs,  tinglings,  rheumatic  pains, 
neuralgia,  neuritis,  general  debility,  and  mental  de- 
pression. 

Dropny  states  that  he  found  indications  of  neuras- 
thenia in  90  per  cent  of  his  cases  of  chronic  prostatitis. 


He  classifies  them 

as 

follows  : — 

Sexual 

... 

.      46-9  % 

Cerebo-spinal 

. 

.      43-8  „ 

Cardiac 

... 

.        4-3  „ 

Gastric 

. 

.        4-9  „ 

Prognosis. — In  a  few^  cases  a  large  proportion  of 
the  gland  is  destroyed  either  as  a  result  of  abscess 
formation  or  of  atrophic  change.  The  desquamation 
of  the  epithelium  and  also  the  periglandular  sclerosis 
lead  to  dilatation  of  the  lumen  of  the  tubules  and 
ducts.  There  is  seldom,  however,  such  complete 
destruction  of  the  essential  glandular  structures  as 
to  negative  the  hope  of  cure.  In  the  great  majority 
of  cases  the  outlook  is  good,  but  treatment  may  have 
to  be  continued  for  a  considerable  time,  especially 

WATSON. — P 


210    GONORRHCEA  &  ITS  COMPLICATIONS 

in  cases  in  which  the  coUiculus  seminahs  is  also  in- 
volved. 

TREATMENT    OF   CHRONIC    PROSTATITIS 

The  objects  to  be  aimed  at  are  the  conservation  of 
the  remaining  healthy  gland  tissue,  the  restitution 
of  the  affected  epithelial  areas,  the  destruction  of  the 
infecting  organisms,  and  the  maintenance  of  a  free 
exit  for  the  secretions. 

The  therapeutic  measure  most  successful  in  attain- 
ing these  ends  is  massage  of  the  gland  through  the 


Fig.  58. 
Watson's  prostatic  masseur. 

rectum.  This  is  most  efficiently  and  safely  carried 
out  by  the  operator's  rubber-protected  forefinger, 
though  by  some  the  iniddle  finger  is  preferred. 
Special  instruments  have  been  devised  for  the  pur- 
pose, but  these  should  only  be  used  when  the  finger 
cannot  comfortably  encompass  the  gland,  and  in 
every  instance  their  use  has  to  be  guided  by  a  pre- 
liminary digital  exploration. 

Figure  58  illustrates  the  design  employed  by  the 
writer  in  the  rare  cases  in  which  the  finger  cannot 
satisfactorily  complete  the  task.  The  whole  pos- 
terior surface  of  each  lobe  must  be  systematically 
gone  over,  working  from  the  lateral  border  to  the 
urethral  sulcus.  The  massage  should  be  continued 
for  two  to  three  minutes,  and  should  be  repeated 
every  second  or  third  day.  It  should  invariably  be 
followed  by  urethro-vesical  lavage,  the  most  generally 


GONOCOCCAL   PROSTATITIS  211 

useful  solution  being  2^oW  ^^  w&o  nitrate  of  silver. 
This  treatment,  by  the  regular  emptying  of  the 
lobules,  prevents  stagnation  of  the  diseased  secretion, 
and  so  discourages  the  formation  of  the  duct  casts 
seen  as  convoluted  threads  in  the  urine.  It  pro- 
motes the  circulation  in  the  gland  and  improves  the 
tone  of  the  musculature. 

Vibratory  massage  has  been  recommended  and 
may  be  used  in  suitable  cases.  There  are  several 
instruments  specially  designed  for  the  purpose,  one 
of  the  most  satisfactory  being  Gunnsett's. 

Electrical  treatment  is  also  warmly  supported  by 
some  who  have  practised  its  application,  and  doubt- 
less it  is  a  useful  adjunct  in  some  cases. 

The  general  treatment  indicated  is  nerve  tonics, 
such  as  glycero-phosphates,  strychnine,  arsenic,  iron, 
quinine,  also  outdoor  exercise,  but  avoiding 
exhaustion.  The  exhibition  of  prostatic  gland  sub- 
stance I  have  found  beneficial  especially  in  neuras- 
thenic cases.  It  is,  however,  extremely  difficult  to 
get  a  sufficient  supply  of  adult  glands.  The  prepara- 
tions in  the  market  are  obtained  from  lambs'  pros- 
tates, and  are  therefore  not  so  active.  The  interaction 
of  the  several  glands  known  to  furnish  internal 
secretions  suggests  the  use  of  thyroid,  pancreatic,  or 
hypophysis  cerebri  extracts.  Thyroid  is  certainly 
helpful  in  a  few  cases. 

That  the  treatment  is  acting  beneficially  is  shown 
by  a  steady  diminution  in  the  number  of  pus  cor- 
puscles in  the  prostatic  secretion,  the  reappearance 
of  free  lecithin  granules,  and  the  disappearance  of 
gonococci.  Complete  absence  of  leucocytes  will  not 
be  attained,  and  their  presence  in  small  numbers  is 
compatible  with  health.  Almost  from  the  beginning 
of    treatment    the    patients    express    themselves    as 


212   GONORRHCEA  &  ITS  COMPLICATIONS 

feeling  invigorated,  and  the  subjective  symptoms 
decrease  in  intensity  until  cure  results,  in  the  majority 
of  cases  within  two  or  three  months. 

No  case  of  gonorrhoea  should  be  discharged  as 
cured  nor  permission  to  marry  be  given  to  one  who 
has  had  gonorrhoea  until  the  condition  of  the  pros- 
tate has  been  investigated. 


CHAPTER  XII 

GONOCOCCAL    VESICULITIS    (SPERMATO-CYSTITIS) 

The  vesiculse  seminales,  on  account  of  their  situation 
near  to  and  their  direct  communication  with  the 
posterior  urethra,  are  hable  to  be  invaded  by  the 
gonococcus,  and  this  occurs  with  much  greater  fre- 
quency than  is  generally  supposed.  As  in  prostatitis, 
a  rectal  examination  is  necessary  for  its  diagnosis, 
and  as  vesiculitis  may  be  a  cause  of  sterility  and  pro- 
longed infectivity  the  possibility  of  its  presence  rein- 
forces the  argument  in  favour  of  rectal  examination 
as  a  routine  procedure  in  all  cases  of  gonorrhoea. 

Anatomy  and  physiology  of  the  vesiculce  sejninales. — 
The  seminal  vesicles  are  two  diverticula  from  the 
vasa  deferentia.  They  lie  against  the  base  of  the 
bladder,  and  are  separated  from  the  second  part  of  the 
rectum  only  by  a  layer  of  recto-vesical  fascia.  They 
extend  upwards  and  outwards  from  the  base  of  the 
prostate  along  the  outer  limits  of  the  triangular  area 
at  the  base  of  the  bladder,  which  is  uncovered  by 
peritoneum.  Their  lower  anterior  ends  lie  near  to 
each  other  and  the  mesial  plane,  but  their  bodies 
diverge  widely  as  they  proceed  upwards,  so  that  pos- 
teriorly they  are  separated  by  a  considerable  interval. 
Each  lies  to  the  outer  side  of  the  ampullated  ends  of 
the  vasa  deferentia  and  overlaps  or  passes  to  the 
outer  side  of  the  vesical  insertion  of  the  ureter  (Fig. 
59).  The  upper  extremity  just  reaches  the  recto- 
vesical reflection  of  the  peritoneum. 

213 


214    GONORRHCEA  &  ITS  COMPLICATIONS 

They  vary  as  regards  size  in  different  individuals. 
The  left  one  is  not  infrequently  larger  than  the  right. 
The  average  length  is  two  inches  (50  millimetres) 
and  breadth  half  an  inch  (14  millimetres).  Each 
vesicle  consists  of  an  irregularly  sacculated  and  con- 
voluted tube  about  five  or  six  inches  (10  to  15  centi- 
metres) long,  and  it  may  be  so  bent  on  itself  that  its 


Fig.  59. 

Diagrammatic  view  of  bladder  from  behind  and  below,  showing  relationship 
between  prostate,  seminal  vesicles,  vasa  deferentia,  and  ureters. 

terminal  cul-de-sac  lies  close  to  its  lower  end.  From 
the  main  tubule  several  branches  are  given  off,  one 
of  which  may  almost  equal  the  primary  tube  in 
length.  The  convolutions  are  bound  together  by 
areolar  tissue,  and  the  whole  organ  is  attached  to  the 
bladder  by  the  recto-vesical  fascia,  beneath  which 
ramify  numerous  branches  of  the  prostatic  plexus  of 
veins.  The  vesicles  have  an  outer  covering  of  con- 
nective tissue,  a  middle  coat  of  non-striated  muscle 


GONOCOCCAL    VESICULITIS 


215 


fibres,  and  a  mucous  membrane  lined  by  cylindrical 
epithelium.  The  mucous  membrane  is  thrown  into 
folds,  and  numerous  trabeculae  give  its  surface  a 
finely  honeycombed  appearance  (Fig.  60).  The  short 
terminal  duct  of  the  vesicle  unites  at  an  acute  angle 
with  the  vas  deferens,  the  conjoined  canal  constituting 
the   ejaculatory   duct.      The   two   ejaculatory   ducts 


Fig.    60. 

Showing  the  internal  structure  of  the  seminal  vesicle  and  of  the  ampulla- 
tion  of  the  vas  deferens^  and  the  union  of  the  two  ducts  which  form  the 
ejaculatory  ducts  :  1^  interior  of  the  seminal  vesicle  ;  2^  interior  of  ampulla  ; 
3,  junction  of  the  ducts  forming  the  ejaculatory  duct.  (The  section  is  taken 
in  transverse  diameter  of  the  prostate,,  and  in  the  long  axis  of  the  seminal 
vesicles  and  vas  deferens.)     (Taylor.) 

lying  side  by  side  enter  the  hilus  of  the  prostate, 
which  they  pierce  to  reach  the  posterior  urethra. 

Physiology. — The  function  of  the  vesicle  is  imper- 
fectly understood.  By  injecting  fluids  into  the  vas 
deferens  the  seminal  vesicles  are  distended,  and  for 
this  reason  it  has  been  assumed  that  the  vesicles  act 
as  a  reservoir  for  the  storage  of  spermatozoa.  That 
spermatozoa  are  found  in  the  expressed  secretion  of 
the  vesicles  lends  no  support  to  this  theory,  because 
it  is  impossible  to  palpate  the  vesicles  without  at  the 


216    GONORRHCEA  &  ITS  COMPLICATIONS 

same  time  compressing  the  adjacent  ampulla  of  the 
vas,  whose  function  is  the  collection  of  the  testicular 
secretion.  On  the  other  hand,  the  similarity  in 
structure  between  the  vesicula  seminalis  and  the 
ampulla  of  the  vas  deferens  suggests  an  identity  of 
function. 

In  guinea-pigs,  rats,  and  some  other  mammals,  the 
vesicles  have  a  separate  and  distinct  duct,  which 
communicates  directly  with  the  urogenital  sinus,  and 
they  never  harbour  spermatozoa.  The  vesicles  have 
therefore  as  another  and  probably  more  important 
function  the  production  of  a  secretion  which  dilutes 
the  semen  and  increases  its  bulk.  It  is  suspected  that 
this  secretion  favours  the  growth  and  activities  of  the 
spermatozoa,  but  no  conclusive  work  on  this  subject 
seems  to  have  been  published.  The  secretion  is  alka- 
line and  odourless.  It  contains  numbers  of  character- 
istic heavy  globules. 

Pathology  and  method  of  examination. — When  either 
of  the  seminal  vesicles  become  infected  the  usual 
desquamative  inflammation  of  the  epithelium  is  in- 
duced. Gonococci  penetrate  into  the  subepithelial 
tissue,  and  round-celled  infiltration  and  thickening  of 
the  wall  occur.  Leucocytes  are  extruded  into  the 
lumen  of  the  tubules,  where  they  become  mixed  with 
the  altered  secretion.  The  contents  of  the  vesicle  are 
then  found  to  consist  of  a  purulent,  viscid  fluid  con- 
taining disintegrated  or  moribund  spermatozoa  epi- 
thelium and  pus  cells,  micro-organisms,  and  serous 
exudation.  The  duct  may  become  temporarily  blocked 
and  the  vesicle  greatly  distended,  in  which  case  it  will 
be  felt,  per  rectum,  as  a  sausage-like  mass  extending 
upward  and  outward  from  the  prostate.  When  in 
a  collapsed  condition  the  seminal  vesicle  is  hardly 
palpable  from  the  rectum.    Contained  secretion  can  be 


GONOCOCCAL   VESICULITIS  217 

expressed,  and  as  it  settles  rapidly  to  the  bottom  of 
the  urine  glass  it  can  easily  be  pipetted.  Examination 
may  show  micro-organisms,  pus  cells,  and  fragments 
of  spermatozoa,  and  these  indicate  infection,  even  if 
enlargement  is  not  demonstrated  by  palpation.  To 
obtain  the  secretion  as  free  from  admixture  with 
extraneous  fluids  as  possible,  it  is  necessary  first  to 
massage  the  prostate,  carefully  avoiding  the  vesicles, 
and  thereafter  to  request  the  patient  to  pass  a  portion 
of  urine  to  wash  out  the  prostatic  and  urethral  secre- 
tions. The  vesicles  are  in  turn  massaged  either  by 
the  finger  or  by  an  instrumental  masseur,  and  on 
again  passing  urine  the  patient  will  expel  the  secre- 
tions which  have  been  displaced  from  the  spermatic 
cysts.  From  the  bottom  of  the  glass  the  material 
which  has  the  appearance  of  sago  grains  should  be 
chosen  for  examination  and  it  should  be  searched  for 
pus  cells,  gonococci,  and  spermatozoa. 

Vesiculitis  may  be  acute  or  chronic.  Hyperacute 
cases  and  abscess  formation  are  rare. 

Acute  vesiculitis. — The  symptoms  of  acute  sper- 
mato-cystitis  are  so  involved  with  those  of  the  accom- 
panying posterior  urethritis  and  prostatitis  that  a 
specific  diagnosis  from  the  subjective  symptoms  is  im- 
possible. The  apposition  of  the  vesicles  against  the 
trigone,  the  most  sensitive  part  of  the  bladder,  renders 
an  inflammation  of  these  sacs  liable  to  excite  aggra- 
vated urinary  symptoms.  Thus  in  addition  to  in- 
creased frequency  of  urination  there  is  often  a  feeling 
of  incomplete  emptying  of  the  bladder,  because  the 
bladder  cannot  fully  contract.  This  is  sometimes 
associated  with  terminal  dribbling  or  suprapubic  or 
deep  perineal  pain.  Pain  is  sometimes  referred  to 
the  inguinal  and  scrotal  region,  suggesting  the  onset 
of   an   epididymitis.      During   the   acute   period   the 


218    GONORRHCEA  k  ITS  COMPLICATIONS 

urethral   discharge   may   be   markedly   decreased   to 
return  affain  as  the  acuteness  subsides. 

As  a  rule  only  one  vesicle  is  affected,  but  at  any 
time  in  the  course  of  the  disease  the  other  may  also 
become  involved.  Seminal  emissions  are  frequently 
blood-stained  and  productive  of  extreme  pain. 

Diagnosis. — Vesiculitis  may  be  inferred  from  the 
bladder  symptoms  and  the  sanguineous  pollutions, 
but  an  exact  diagnosis  will  depend  on  the  discovery 
of  an  enlarged  and  tender  vesicle  by  rectal  palpation 
or  on  the  microscopic  demonstration  of  pus  in  the 
expressed  secretion. 

In  the  way  of  treatment  there  are  no  special 
indications  other  than  have  already  been  considered 
in  previous  chapters.  All  manipulative  interference 
must  be  rigorously  avoided  in  the  acute  stages. 
Atropine  has  here  a  particular  value  as  a  prophylactic 
measure  against  spread  of  the  infection  along  the  vas 
deferens  to  the  epididymis.  Hyoscyamus  and  phe- 
nacetin  may  control  the  vesical  irritation,  but  if  not, 
opium  or  its  derivatives  will  be  required.  Hot  irriga- 
tion through  the  rectal  tube  will  be  found  very 
soothing. 

Course  of  the  disease  and  prognosis. — The  great 
majority  of  cases  of  vesiculitis  are  mild  or  subacute. 
Hyperacute  cases  with  perivesiculitis  are  rare.  Abscess 
formation  is  seldom  seen.  When  it  does  occur 
an  exit  is  found  through  the  ejaculatory  duct  into 
the  posterior  urethra,  and  only  in  very  exceptional 
cases  is  any  operative  interference  required.  In 
ordinary  cases  resolution  may  be  anticipated  in  two 
to  three  weeks,  but  there  is  always  a  tendency  to 
lapse  into  the  chronic  form. 

Chronic  vesiciditis. — In  chronic  spermato-cystitis 
the  symptoms  are  frequency  of  micturition,  perineal 


GONOCOCCAL   VESICULITIS  219 

discomfort,  sterility  due  to  destruction  of  the  sperma- 
tozoa, and  painful  sanguineous  pollutions. 

The  walls  of  the  chronically  inflamed  vesicles 
become  thickened,  and  owing  to  fibrous  changes  and 
adhesions  their  contractile  powers  and  control  over 
their  contents  are  decreased.  The  secretion  may 
escape  during  any  straining  effort,  and  it  may  over- 
flow during  the  night.  In  this  way  some  cases  of 
gleety  discharge  may  be  explained.  The  discharge 
in  these  cases  if  examined  will  be  found  to  contain 
spermatozoa  more  or  less  disintegrated. 

Insomnia  and  neurasthenia  with  polyuria  may  be 
induced  by  vesiculitis.  Spermato-cystitis  is  usually 
associated  with  prostatitis,  but  the  latter  may  resolve 
earlier  than  the  inflammation  of  the  vesicles.  Sub- 
jective symptoms  for  the  two  affections  cannot  be 
separated,  but  rectal  palpation  and  examination  of  the 
centrifugate  from  the  urine  after  massage  as  already 
described  will  enable  the  true  condition  to  be  diagnosed. 

Stricture  is  the  scapegoat  which  has  to  bear  the 
blame  for  all  the  symptoms  produced  by  prostatitis 
and  vesiculitis  ;  but  there  is  little  difficulty  in  recog- 
nising a  stricture  when  it  is  present  and  in  obviating 
its  harmful  effects.  Once  this  has  been  accomplished, 
if  symptoms  still  remain  unrelieved,  a  systematic 
examination  will  in  many  cases  discover  a  chronic 
vesiculitis  or  prostatitis  or  both. 

Treatment. — The  general  health  should  receive  every 
attention.  The  bowels  are  regulated  by  saline  aperi- 
ents, and  such  diet,  exercise,  and  bathing  enjoined  as 
is  suitable  for  the  patient's  condition.  Urinary  anti- 
septics such  as  urotropin,  helmitol,  salol,  boric  acid, 
and  sedatives  such  as  hyoscyamus,  phenacetine,  atro- 
pine, codeine,  or  morphine  will  occasionally  be  re- 
quired. 


220    GONORRHOEA  &  ITS  COMPLICATIONS 

Coexisting  conditions  such  as  a  posterior  urethritis, 
stricture,  or  prostatitis  should  receive  appropriate 
treatment. 

Massage  of  the  vesicle  is  of  considerable  value  in  the 
cure  of  chronic  inflammatory  conditions.     Care  must 
be  used   in   the   exertion   of  pressure  to   avoid   any 
possibility   of   exciting   irritation.      The   finger,    well 
lubricated,  will  reach  the  vesicles  beyond  the  prostate 
about  2j  inches  from  the  anus,  and  it  should  foliow 
the  structure  laterally  and  upwards  to  its  limit,  and 
then  begin  a  gentle  side-to-side  and  downward  move- 
ment with  the  object  of  pressing  out  the  contents  of 
the   sacs,   softening   the  walls,   and   stimulating   the 
circulation,  thus  promoting  absorption  and  muscular 
tone.     The  patient  adopts  a  slight  bending  posture, 
kneeling  on  a  chair.     The  bladder  should  be  fully 
distended  to  bring  the  vesicles  well   down  into  the 
pelvis.    As  a  rule,  I  find  I  can  reach  the  vesicles  most 
comfortably  with  the  palmar  surface  of  the  finger 
turned  backwards,   that   is   turned   in  the   direction 
opposite  to  that  which  is  adopted  while  palpating  the 
prostate.     In  this  case  the  nail  or  the  extreme  end  of 
the  finger  is  the  pressing  point.    The  massage  should 
be  repeated  every  two  to  four  days,  and  each  applica- 
tion should  last  from  three  to  ten  minutes.     At  first 
the  amount  of  secretion  expressed  may  be  trifling, 
but  as  the  cyst  softens  the  quantity  of  detritus  which 
may    be    expelled    is    often    surprising.      Sometimes 
what  is  evidently  a  cast  of  the  vesicle  is  passed  in  the 
urine   after   massage.      In   addition   to   regularly  re- 
peated  massage,   electrical  treatment  is   one   of  the 
most  useful  modes  of  attaining  the  same  results. 

The  vesicles  are  not  amenable  to  direct  medication 
from  the  urethral  canal,  but  Belfield  has  suggested 
and   carried   out   a   procedure   which    may    in    some 


GONOCOCCAL   VESICULITIS  221 

cases  be  of  considerable  value.  His  method  consists  in 
attacking  the  vesicle  from  the  vas  deferens  in  the  sper- 
matic cord,  which  he  isolates  with  the  finger  and  thumb 
and  fixes  by  passing  a  half -curved  needle  through  the 
scrotal  skin  and  under  the  vas.  Under  local  anassthesia, 
a  half-inch  incision  through  the  skin  and  sheath  of  the 
spermatic  cord  exposes  the  vas,  which  is  then  opened 
by  a  small  transverse  or  longitudinal  cut.  The 
blunted  needle  of  a  hypodermic  syringe  will  pass  iato 
the  minute  canal,  and  the  chosen  solution,  not  ex- 
ceeding thirty  minims  in  bulk  to  begin  with,  is 
injected,  traversing  the  vas  and  ampulla  and  distend- 
ing the  seminal  vesicle.  A  greater  quantity  than 
thirty  minims  is  liable  to  excite  painful  contraction 
of  the  vesicle  (spermatic  colic).  When  it  is  desired 
to  retain  a  fistulous  opening  for  daily  injections  or 
for  drainage  of  the  ampulla,  the  vas  is  stitched  to 
the  skin  by  a  fine  suture  passing  through  the  wall  of 
the  vas  on  each  side  of  the  incision  wound.  When 
the  course  of  injections  is  completed  the  fistula  can 
easily  be  closed  by  suture.  Belfield  has  proved  by 
experiments  on  dogs,  as  well  as  by  the  after  effects  on 
man,  that  the  lumen  of  the  canal  is  not  affected  by 
this  operation. 


CHAPTER  XIII 

GONOCOCCAL   EPIDIDYMITIS 

Epididymitis,  in  the  vast  majority  of  cases,  is  the 
product  of  gonococcal  infection.  Gout,  influenza, 
tonsihtis,  trauma,  etc.,  may  in  occasional  cases  be 
responsible  for  the  onset  of  an  inflammation  of  the 
epididymis,  but  the  usual  cause  is  the  conveyance 
of  the  gonococcus  from  the  posterior  urethra,  via 
the  vas  deferens,  either  by  direct  extension  of  the 
inflammatory  process  or  more  probably  by  reversed 
peristaltic  action.  Tubercle  is  liable  to  attack  the 
epididymis ;  syphilis  is  more  prone  to  affect  the 
testicle,  as  also  is  the  rare  inflammation  associated 
with  the  infectious  fevers. 

Guiteras,  who  has  had  a  large  experience  of  these 
conditions,  states  that  85  per  cent  of  epididymitis  is 
gonococcal,  10  per  cent  tuberculous,  and  5  per  cent 
due  to  other  causes. 

By  taking  the  average  of  several  published  statistics 
(Finger,  Rollet,  Jullien,  Tarnousky,  and  others), 
Neisser  estimated  that  27  per  cent  to  29  per  cent  of 
cases  of  gonorrhoeal  infection  in  hospitals  and  12 
per  cent  to  17  per  cent  of  cases  treated  as  out-patients 
suffered  from  epididymitis.  Neisser  therefore  adopts 
the  mean  of  the  above,  16  per  cent,  as  the  incidence 
of  epididymitis. 

This  method  of  calculation  is,  however,  of  no 
value  in  attempting  to  determine  the  real  incidence  of 

222 


GONOCOCCAL   EPIDIDYMITIS         223 

epididymitis,  as  a  large  proportion  of  cases  of  epididy- 
mitis seek  treatment  and  only  a  small  proportion  of 
cases  of  urethritis.  Only  cases  in  which  this  compli- 
cation has  eventuated  while  the  patient  was  already 
under  observation  should  be  included,  and  as  such 
cases  would  all  be  undergoing  treatment  there  would 
be  no  basis  on  which  to  calculate  its  occurrence  in 
the  great  mass  of  untreated  or  insufficiently  treated 
cases.  Probably  it  would  not  be  far  from  the  actual 
facts  to  estimate  the  incidence  at  6  per  cent  under 
suitable  treatment,  and  a  still  higher  ratio  in  untreated 
cases. 

Epididymitis  most  commonly  arises  in  the  second, 
third,  or  fourth  week  of  an  acute  gonorrhoea,  that  is  to 
say,  shortly  after  the  involvement  of  the  posterior 
urethra.  It  may,  however,  be  excited  at  any  time  in 
the  course  of  an  acute  or  chronic  infection  located  in 
the  posterior  urethra  or  its  communicating  cavities. 
It  may  be  that  the  occurrence  of  the  epididymitis  calls 
attention  to  the  presence  of  a  previously  unsuspected 
chronic  infection. 

Some  individuals  show  an  idiosyncrasy  towards  the 
development  of  an  epididymitis.  In  such  cases  every 
attack  of  gonorrhoea  is  followed  by  this  complication. 

The  right  and  left  sides  are  affected  with  almost 
equal  frequency.  Very  rarely  are  both  concurrently 
attacked,  but  the  one  epididymis  may  become  in- 
volved at  a  variable  interval  after  the  other.  Walson 
found  in  one  hundred  cases  the  following  dates  of 
onset  : — 

Number  of  Previous  existence  of 

cases.  gonorrhcEa. 

6  1  week 

14  '  2  Aveeks 

a  3    „ 


224    GONORRHCEA  &  ITS  COMPLICATIONS 


Number  of 

Previous  existence  of 

cases. 

gonorrhcea. 

18 

4  weeks 

1 

5 

2 

6 

4 

'^ 

12 

8 

8 

9 

3 

10 

31 

more  than  10       ,, 

Twelve  of  the  above  were  recurrent  attacks.  As 
regards  situation,  forty-seven  cases  were  on  the  right 
side  and  forty-five  on  the  left  side.  In  eight  cases 
both  sides  were  involved  during  the  course  of  the 
gonorrhoea.  These  figures  agree  closely  with  those 
of  other  observers  (Neisser  and  others). 

Anatomy. — Towards  the  upper  j^art  of  the  pos- 
terior border  of  the  testicle  the  efferent  tubules  (vasa 
efferentia),  twelve  to  twenty  in  number,  unite  to  form 
a  single  duct,  the  canal  of  the  epididymis.  This  fine 
tube  is  disposed  in  a  great  series  of  convolutions. 
When  these  are  unravelled  the  total  length  is  found 
to  approximate  to  twenty  feet  (6  metres).  The 
upper  bulkier  part  of  the  epididymis  is  known  as  the 
globus  major,  or  head,  the  lower  part  as  the  globus 
minor,  or  tail,  and  the  intervening  portion  as  the 
body.  From  the  globus  minor  the  duct  emerges  with 
gradually  thickening  walls  and  widening  lumen  to 
form  the  vas  deferens.  The  canal  of  the  epididymis 
varies  from  -4  millimetre  to  -27  millimetre  in 
diameter.  It  has  thin  walls  with  an  external  longi- 
tudinal and  an  internal  circular  layer  of  muscular 
fibres  and  an  epithelial  lining  of  ciliated  columnar 
cells  (Fig.  61).  The  cilia  disappear  towards  the  loAver 
part  of  the  epididymis.    The  globus  major  is  attached 


GONOCOCCAL   EPIDIDYMITIS 


225 


to  the  testicle  by  fibrous  tissue,  the  vasa  eff  erentia,  and 
a  reflection  of  the  tunica  vaginaHs.  The  globus  minor 
also  is  attached  to  the  testicle,  but  only  by  areolar 
tissue  and  the  tunica  vaginalis.  The  globus  major 
caps  the  postero-superior  border  of  the  testicle. 

The  vas  deferens  ascends  upon  the  inner  side  of  the 
epididymis  at  the  back  of  the  testicle.  It  accom- 
panies the  spermatic  vessels  and  nerves  in  the  sper- 


FiG.  61. 

Showing  section  of  a  tubule  of  the  human  epididymis  :  1,  membrana 
pi'opria  ;  2,  columnar  cells  crowned  with  3,  long  cilia ;  4,  layer  of  non- 
striped  muscular  fibres  ;  5,  intertubular  connective  tissue  ;  i'l,  masses  of 
spermatozoa  in  the  lumen  of  the  tube.     (Taylor  after  Pearsol.) 

matic  cord,  where  it  can  be  felt  like  a  piece  of  fine 
whip-cord.  Leaving  the  spermatic  vessels  at  the 
internal  inguinal  ring,  it  courses  downwards  over  the 
side  of  the  bladder  to  the  base,  where  it  becomes  en- 
larged and  sacculated  to  form  the  ampulla.  Distal 
to  the  ampulla  it  again  contracts,  and  uniting  with 
the  duct  of  the  seminal  vesicle  constitutes  the  ejacu- 
latory  duct  (Fig.  62). 


Fig.  62. 

Diagram  to  show  connection  between  prostatic  urethra^  seminal  vesicles, 
and  epididymis. 

A. — Vasa  eiFerentia. 

B. — Globus  major. 

C. —      ,,      minor. 

D. — Vas  deferens  in  spermatic  cord. 

E. —  ,,  ,,       ,^  inguinal  canal. 

F. —  ,,  ,^       ^,  abdomen. 

G. — Ampulla  of  vas  deferens. 

H. — Seminal  vesicle. 

I.  — Ejaculatory  duct. 

K. — Urinary  bladder. 

L.  — Prostatic  urethra. 


GONOCOCCAL   EPIDIDYMITIS         227 

The  vas  measures  about  a  foot  in  length  (300  milh- 
metres),  and  has  an  average  diameter  of  2-5  milh- 
metres  and  a  lumen  of  -7  millimetre.  The  thickness 
of  the  wall  is  due  to  the  quantity  of  muscular  tissue. 
The  epithelium  is  columnar,  but  not  ciliated.  The 
ampulla  is  very  similar  to  the  seminal  vesicle  in 
structure  and  appearance. 

Etiology. — Fluid  tapped  from  the  inflamed  epididy- 
mis usually  yields  the  gonococcus  in  pure  culture. 
The  gonococcus  reaches  the  epididymis  from  the 
posterior  urethra  or  seminal  vesicle  by  a  reversed 
peristaltic  action  of  the  vas  deferens.  Low  and 
Oppenheim  demonstrated  this  fact  by  electrical 
stimulation  of  the  ejaculatory  duct  of  a  patient 
recently  infected  with  gonorrhoea.  A  vermicular 
movement  of  the  vas  deferens  in  the  direction  of  the 
epididymis  could  be  felt  by  the  hand,  and  an  acute 
epididymitis  resulted  from  which  the  gonococcus  was 
isolated.  Schindler,  by  experiments  on  animals, 
showed  that  irritation  of  the  prostate  and  colliculus 
seminalis  initiated  this  reversed  movement,  and  that 
by  atropine  such  currents  could  be  inhibited.  A 
careful  examination  will  usually  prove  that  the  sem- 
inal vesicle  of  the  same  side  is  antecedently  or  con- 
currently involved. 

Bronium  found  the  gonococcus  in  the  secretion  of 
the  seminal  vesicles  of  the  affected  side  in  80  per  cent 
of  his  cases,  and  in  the  other  20  per  cent  pus  cells 
were  present. 

Exciting  causes  are  trauma,  irritation  from  exces- 
sive local  treatment  or  passage  of  instruments, 
sexual  excitement,  and  delay  in  emptying  a  full 
bladder.  Any  agency  which  will  increase  the  in- 
tensity of  the  inflammation  will  tend  to  excite  an 
epididymitis,  hence  the  importance  of  avoiding  all 


228    GONORRHCEA  &  ITS  COMPLICATIONS 

instrumentation  in  acute  conditions  and  the  adoption 
only  of  such  treatment  as  will  have  a  sedative  effect. 
Cases  have  been  reported  by  careful  observers 
(Neisser,  Jadassohn,  and  others)  in  which  the  pos- 
terior urethra  had  been  skipped  by  the  inflammatory 
process.  Such  an  appearance  may  be  explained  by 
the  supposition  that  the  gonococci,  which  reached 
the  prostatic  urethra,  had  been  swept  away  by  the 
urine  stream,  with  the  exception  of  a  few  which  had 
been  deposited  in  the  orifice  of  an  ejaculatory  duct. 
An  even  more  probable  explanation  is  that  the  pos- 
terior urethritis  at  the  time  of  observation  was 
quiescent  or  cured,  but  that  the  gonococcus  had 
secured  a  footing  in  the  seminal  vesicle.  Infection  of 
the  epididymis  by  the  blood  stream  is  conceivable  as 
part  of  a  general  infection,  but  in  such  cases  there 
would  be  corroborative  evidence  in  the  way  of  joint 
or  endocardial  disease.  If  any  cases  of  gonorrhoeal 
epididymitis  owe  their  origin  to  this  source  it  must 
only  be  a  fractional  percentage. 

A  number  of  cases  are  on  record  in  which  epididy- 
mitis preceded  the  urethritis.  These  have  been  cases 
of  relapsing  gonorrhoea  and  not  fresh  infections. 

The  vas  deferens  may  or  may  not  show  signs  of 
inflammation  (deferenitis,  funiculitis).  The  tube  of 
the  vas  is  not  necessarily  acutely  implicated  in  the 
gonorrhoeal  process.  The  transference  of  infected 
material  from  the  posterior  urethra  to  the  epididymis 
is  effected,  as  has  already  been  shown,  by  a  reversed 
peristalsis.  While  the  ampulla  of  the  vas  is  fre- 
quently involved  concurrently  with  the  seminal 
vesicle  the  tissues  of  the  vas  are  more  resistant  to 
the  action  of  the  gonococcus,  and  therefore  an 
acutely  inflamed  vas  is  comparatively  uncommon. 
In  this  respect  the  vas  is  comparable  to  the  mem- 


GONOCOCCAL   EPIDIDYMITIS         229 

branous  urethra.  Some  tenderness  of  the  cord  may 
be  elicited  by  pressure  at  the  external  inguinal  ring 
some  hours  before  the  appearance  of  any  scrotal 
swelling,  and  this  is  one  of  the  initial  symptoms  sug- 
gestive of  the  onset  of  epididymitis. 

Pathology. — The  cauda  epididymis,  the  most  de- 
pendent part,  is  usually  the  first  to  show  evidence  of 
inflammation.  The  body  and  head  are  soon  in- 
volved and  the  resulting  swelling  may  be  general,  or 
more  pronounced  either  in  the  upper  or  lower  globes. 
The  lateral  surfaces,  as  well  as  the  two  poles  of  the 
testicle,  are  encroached  upon  by  the  enlarging  epi- 
didymis. By  following  the  groove  between  the  over- 
lapping epididymis  and  the  invaginated  testicle,  it 
may  be  possible  to  form  some  idea  of  the  size  of  the 
latter  and  thus  to  determine  whether  it  is  implicated 
to  any  extent  in  the  inflammatory  process  (epididymo- 
orchitis).  This,  however,  is  quite  unusual,  the 
pathological  condition  being  confined  to  the  epididy- 
mis when  the  gonococcus  alone  is  the  infecting 
agent.  There  is  usually  some  effusion  into  the 
tunica  vaginalis  forming  a  temporary  hydrocele,  and 
this  increases  the  difficulty  of  delineating  the  struc- 
tures. 

A  severe  inflammatory  reaction  is  induced  in  the 
connective  tissue  surrounding  the  convolutions  of  the 
epididymis.  Exudation  collects  in  the  interstitial 
spaces  ;  the  lumen  of  the  canal  becomes  occluded 
at  various  points  by  the  pressure  of  this  exu- 
date, and  pools  of  sero-purulent  secretion  containing 
leucocytes,  desquamated  epithelium,  and  gonococci 
distend  the  intervening  portions  of  the  tube.  Small 
abscesses  are  a  frequent  result. 

The  hydrocele  fluid  in  many  cases  is  found  to  con- 
tain gonococci.     In  quantity  it  varies  from  a  few 


230    GONORRHCEA  &  ITS  COMPLICATIONS 

drams  to  a  few  ounces.  In  a  small  percentage  of 
cases  the  exudation  becomes  solidified,  and  the  re- 
sulting fibrinous  layer  produces  more  or  less  adhesion 
between  the  parietal  and  visceral  surfaces  of  the 
tunica  vaginalis. 

In  nearly  all  cases  there  is  some  formation  of  false 
membrane  on  the  surface  of  the  epididymis.  This 
is  composed  of  fibrin,  leucocytes,  and  cell  detritus, 
and  it  closely  resembles  the  exudate  found  on  synovial 
membranes  in  gonorrhoeal  arthritis.  A  leucocytosis 
of  over  30,000  may  be  present.  Where  a  high  leu- 
cocyte count  is  found,  small  abscesses  are  usually,  but 
not  always,  present. 

The  scrotum  in  many  cases  is  red,  swollen,  and 
oedematous  :  a  brawny  condition  of  the  scrotum  is 
most  marked  when  there  is  little  or  no  hydrocele 
effusion. 

Symytoms. — An  observant  patient  may  notice  in- 
guinal discomfort  and  tenderness  a  few  hours  in 
advance  of  the  first  symptom  referable  to  the  testicu- 
lar region.  He  will  next  be  conscious  of  a  sensation 
of  burning  at  the  postero-inferior  angle  of  the  testicle. 
Swelling  and  considerable  pain  are  soon  prominent 
symptoms  progressive  during  the  first  few  days  until 
the  affected  side  of  the  scrotum  has  reached  the  size 
of  a  closed  fist.  In  acute  cases  the  swelling  increases 
rapidly,  the  scrotum  becomes  red  and  oedematous, 
fluid  accumulates  in  the  tunica  vaginalis,  and  the 
whole  mass  is  too  tender  to  stand  the  manipulation 
necessary  to  outline  in  detail  the  confines  of  the 
testicle  and  surrounding  epididymis.  Lymphangitis 
is  sometimes  responsible  for  considerable  pain  along 
the  course  of  the  spermatic  cord.  The  temperature 
may  rise  to  103°  F.  or  104°  F.,  but  fever  is  only 
present  during  the  progressive  stage. 


GONOCOCCAL   EPIDIDYMITIS         231 

The  stationary  stage  is  reached  in  three  to  five  days, 
lasts  about  a  similar  period,  and  is  followed  by  a 
slower  resolution.  As  soon  as  the  swelling  reaches  its 
maximum  the  extreme  pain  abates  if  the  scrotum  is 
properly  supported.  The  pain  may  be  intense  ;  it 
is  often  of  a  sickening  nature  and  liable  to  produce 
a  feeling  of  faintness.  In  subacute  cases  the  symp- 
toms are  similar  but  less  severe  ;  the  duration  of 
each  stage  is  reduced  by  a  day  or  two,  and  con- 
valescence is,  as  a  rule,  more  rapid  and  complete. 

Diagnosis. — The  medical  attendant  has  first  of  all 
to  satisfy  himself  that  the  case  is  one  of  epididymitis 
as  against  orchitis ;  and,  secondly,  that  it  is  of 
gonorrhoeal  origin.  The  first  is  ascertained  by 
questioning  as  to  the  point  where  the  pain  and 
swelling  originated  and  the  digital  examination  of 
the  inflamed  mass.  The  occurrence  of  an  acute 
hydrocele  may,  when  necessary,  be  demonstrated  by 
a  trochar.  The  gonococcal  nature  of  the  disease 
is  proved  by  evidence  of  infection  elsewhere,  which, 
however,  may  have  to  be  carefully  searched  for.  The 
patient  may  attempt  to  suppress  the  history  of  a 
urethritis.  A  recently  passed  urine  will,  however,  in 
most  cases  show  threads  and  flakes  of  purulent  secre- 
tion, and  a  rectal  examination,  conducted  with  the 
greatest  gentleness,  should  be  undertaken  to  deter- 
mine the  condition  of  the  prostate,  of  the  posterior 
urethra,  and  particularly  of  the  vesicula  seminalis  of 
the  corresponding  side.  The  discharge  of  an  acute 
urethritis  often  declines  during  the  progressive  stage 
of  an  epididymitis,  and  it  may  entirely  disappear  for 
a  time,  to  return  in  most  cases  on  the  subsidence  of 
the  epididymitis.  This  phenomenon  is  probably 
dependent  on  the  formation  of  antibodies  in  response 
to  the  quantity  of  gonotoxine  entering  the  circulation 


232    GONORRHCEA  &  ITS  COMPLICATIONS 

through  the  spermatic  lymphatics  and  veins.  The 
absence  of  external  discharge  may,  in  such  cases,  be 
apt  to  mislead,  but  a  scrutiny  of  the  urine  will  pre- 
vent misconception. 

Tubercular  epididymitis  is  distinguished  by  its 
slow  development,  by  the  fact  that  it  originates 
most  frequently  in  the  globus  major,^  and  by  the 
presence  of  tubercular  disease  in  other  parts  of  the 
genito-urinary  system,  e.g.,  the  vas  deferens,  seminal 
vesicles,  prostate,  or  trigone  of  the  bladder.  Tuber- 
culosis of  the  vesicles  and  prostate  is  characterised 
by  the  occurrence  of  small  scattered  nodules  which, 
on  palpation  through  the  rectum,  are  found  to  be 
hard  and  practically  free  from  tenderness.  In  acute 
orchitis  due  to  metastatic  infection  or  to  mumps,  the 
inflammation  is  limited  to  the  testicle  itself ;  there 
are  no  threads  in  the  urine,  and  there  is  no  perineal 
discomfort. 

Prognosis. — The    more    severe    cases    are    usually 
retrogressing  and  able  to  be  out  of  doors  within  the 
fortnight,  but  complete  resolution  may  take  several 
weeks  longer.     When  the  parts  finally  have  returned 
to  their  normal   appearance,   careful  palpation  will 
frequently  show  the  presence  of  a  chronic  nodular 
infiltration  in  the  substance  of  the  epididymis.    These 
nodules  may  be  found  either  in  the  globus  major  or 
minor.    They  usually  indicate  complete  obstruction  of 
the  canal  and  sterility  as  regards  the  testicle  con- 
cerned.    Should  the  nodule  be  situated  in  the  globus 
major  above  the  point  of  entrance  of  any  of  the  vasa 
efferentia,   only  partial   deprivation   of  spermatozoa 
will  result.     If  epididymitis  has  affected  both  sides, 
and    nodules    are    left,    complete    sterility    may    be 
anticipated.      This,    however,    does    not    entail    im- 
potency  ;    sexual  desire  and  power  are  unimpaired. 


GONOCOCCAL   EPIDIDYMITIS         233 

but  the  ejaculated  semen,  although  apparently 
normal,  is  entirely  deficient  in  spermatozoa.  Benzler 
collected  the  paternity  statistics  of  a  number  of 
German  ex-soldiers  who,  while  serving  with  the 
colours,  had  contracted  gonorrhoea.  He  found  that 
three  years  after  marriage  10-5  per  cent  of  those  who 
had  suffered  from  gonorrhoea  without  epididymitis 
were  childless,  while  23-4  per  cent  of  those  with  uni- 
lateral epididymitis  were  sterile,  and  41-7  per  cent  of 
those  who  had  been  affected  with  double  epididy- 
mitis had  no  children.  Keyes  points  out  that  liability 
to  relapse  presupposes  a  patent  canal,  and  therefore 
freedom  from  sterility  ;  but  this  cannot  be  accepted 
as  an  absolute  rule,  as  the  canal  may  be  blocked  at 
a  point  high  enough  to  prevent  entrance  through 
the  vasa  efferentia  of  any  spermatozoa,  and  yet 
leaving  a  considerable  length  of  tube  freely  accessible 
to  infection  from  below. 

Treatment. — Prophylaxis  is  best  served  by  the 
scrupulous  observation  of  gentleness  in  treating  the 
posterior  urethra,  by  the  use  of  atropine  in  sufficient 
doses  as  suggested  by  Schindler,  and  by  the  applica- 
tion of  a  suitable  suspensory  bandage. 

Complete  rest  in  bed  is  desirable  in  all  cases  of 
epididymitis,  at  least  during  the  progressive  stage. 
Ambulatory  treatment  has  to  be  conceded  for  per- 
sonal reasons  in  some  cases,  but  it  entails  greater 
suffering  and  delayed  cure.  The  main  indications  are 
the  relief  of  pain  and  the  reduction  of  the  swelling, 
and  these  results  are  best  obtained  by  rest  and  eleva- 
tion. In  recumbent  cases  elevation  can  be  secured 
by  means  of  a  platform  of  broad  adhesive  plaster 
stretched  across  the  thighs  for  the  support  of  the 
scrotal  contents,  but  a  properly  devised  suspensory 
bandage  is  preferable  as  it  allows  of  greater  freedom 


234    GONORRHCEA  &  ITS  COMPLICATIONS 

of  movement.  In  ambulatory  cases  some  form  of 
suspensory  bandage  is  compulsory.  The  old-fashioned 
commercial  suspensory  is  of  little  use,  but  some  of 
more  recent  introduction  are  satisfactory,  e.g.,  Johnson 
and  Johnson's  Red  Cross  Athletic  Bandage.  A  com- 
bined T  and  triangular  bandage  may  be  improvised  for 
the  support  of  the  parts  from  an  ordinary  triangular 
bandage  with  a  forty-inch  base  in  the  following  manner. 
A  two-inch  strip  is  cut  along  the  base  of  the  bandage 
up  to  two  inches  from  its  centre  on  each  side,  leaving 
a  waistband  with  a  four-inch  attachment  to  the 
base  of  the  now  smaller  triangle.  Similar  or  some- 
what narrower  strips  are  slit  along  the  sides  until 
within  two  inches  of  the  apex.  The  basal  strips  are 
tied  round  the  waist,  the  padded  scrotum  hoisted 
snugly  within  the  reduced  triangle,  which  is  then 
attached  firmly  to  the  waistbelt  behind  by  means  of 
the  lateral  strips.  An  opening  is  cut  at  a  suitable 
point  for  the  escape  of  the  penis.  The  scrotum  is 
surrounded  by  a  layer  of  cotton-wool  or  gauze  satu- 
rated with  whatever  dressing  has  been  prescribed. 
This  is  covered  by  a  sheet  of  oiled  silk,  and  the 
testicle  hoisted  well  up  before  applying  the  perineal 
bandage  (Fig.  63).  A  small  triangular  bandage  may 
also  be  used  in  a  reversed  manner  by  attaching  to  the 
centre  of  the  base  a  strip  of  tape  or  bandage  with 
which  it  is  fixed  to  a  waistband  posteriorly.  The  base 
of  the  triangle  (fourteen  inches  long)  should  be 
placed  under  the  scrotum,  the  ends  brought  up  on 
each  side  in  the  groin  and  tied  to  the  waistband.  Any 
loose  folds  are  then  bunched  together  and  with  the 
apex  pinned  to  the  waistband  in  front.  Cotton-wool 
and  oiled  silk  should  always  envelop  the  scrotum 
beneath  the  supporting  bandage. 

For  the  relief  of  pain  the  remedy  in  most  general 


GONOCOCCAL   EPIDIDYMITIS 


235 


use  is  moist  heat  in  the  form  either  of  fomentations 
or  poultices.  Cold  has  been  much  used  on  the  Conti- 
nent, but  it  is  not  so  comforting,  and  the  prolonged 
use  of  an  ice  bag  by  devitalising  the  tissues  is  not 
without  risk.  It  is  now  recognised  that  the  tendency 
to  nodular  remnants  is  increased  by  the  cold  method 
of  treatment. 

Guiteras  advises  the  use  of  the  Paquelin  cautery 
for  the  relief  of  pain  in  cases  which  have  to  be  treated 


Fig.  63. 
Application  of  the  modified  triangular  bandage. 


without  confinement  to  bed.  As  I  have  no  experience 
of  the  method,  I  will  give  his  description  verbatim. 
"  We  grasp  the  affected  testis  in  the  left  hand  to 
steady  it,  and  then  brush  the  cautery  blade  at  white 
heat  lightly  over  the  surface  of  the  scrotum  in  quick 
sweeps,  just  grazing  the  skin.  This  is  done  in  several 
places,  leaving  reddish  stripes  as  the  evidence  of  the 
cautery  application.  The  effect  of  such  treatment 
is  often  incredible,  and  I  have  at  times  seen  patients 
come  limping  into  the  hospital  apparently  suffering 


236    GONORRHCEA  &  ITS  COMPLICATIONS 

most  excruciating  pain,  who  were  almost  immediately 
relieved  of  their  pain  by  the  application  of  the 
cautery." 

Local  external  applications. — Many  remedies  have 
been  recommended  for  application  to  the  scrotum. 
Amongst  those  which  have  attained  the  greatest 
vogue  are  ichthyol  in  glycerine  (10  to  50  per 
cent),  guiacol  in  spirit,  glycerine  or  vaseline 
(10  to  15  per  cent),  and  extract  of  belladonna 
in  glycerine  (10  per  cent).  The  most  satisfactory  of 
these  is  a  20  per  cent  solution  of  ichthyol  in  glycerine 
applied,  when  the  fomenting  stage  is  past,  on  lint 
covered  by  oiled  silk  and  supported  by  cotton-wool 
inside  a  suspensory  bandage.  As  an  alternative,  one 
of  the  menthol  and  salicylic  acid  lanoline  pastes  or 
one  of  the  infusorial  earth  and  glycerine  preparations 
such  as  antiphlogistine  might  be  used.  Guiacol  is 
liable  to  set  up  dermatitis,  while  belladonna  absorp- 
tion may  give  rise  to  symptoms  of  poisoning,  es- 
pecially if  atropine  is  at  the  same  time  being  ad- 
ministered internally.  Absorption  through  the  scrotal 
skin  takes  place  with  great  facility. 

Leeches  were  at  one  time  largely  employed,  but  in 
such  a  vascular  part  the  resulting  haemorrhage  may  be 
troublesome  and  difficult  to  control.  Strapping  of  the 
testicle  is  frequently  used,  but  it  is  difficult  by  this 
method  to  maintain  any  satisfactory  constant  pres- 
sure. When  compression  is  desired  to  assist  absorp- 
tion, a  short  elastic  bandage  fixed  by  adhesive  plaster 
is  preferable. 

The  Bier  method  has  been  extensively  employed, 
and  favourably  reported  upon.  The  passive  hyper- 
semia  is  induced  by  a  constricting  rubber  tube  or 
bandage  applied  over  a  layer  of  cotton-wool  in  such 
a  manner  as  to  include  only  the  affected  side  of  the 


GONOCOCCAL   EPIDIDYMITIS 


237 


scrotum  (Fig.  64).  The  amount  of  pressure  to  main- 
tain is  regulated  by  the  subjective  sensation  of  the 
patient.  The  constricting  band  is  kept  in  position 
for  one  hour  at  the  first  apphcation.  The  duration 
of  the  treatment  is  doubled  each  day  until  a  period 
of  eight  hours  is  reached.  This  method  is  not  suit- 
able in  general  practice,  as  it  requires  the  constant 
attention  of  a  skilled  nurse,  but  in  hospital  I  have 
found  it  of  decided  value. 


Fig.  64. 
Epididymitis  and  paraphimosis.      Bier  treatment  of  epididymitis  applied. 


General  treatment. — The  diet  should  be  suitably 
restricted.  The  bowels  should  be  cleansed  with  a 
brisk  saline  aperient  each  morning.  It  is  usually 
recommended  that  all  local  treatment  of  the  posterior 
urethra  and  its  adnexa  should  be  discontinued  for  the 
first  week  at  least.  When  it  can  safely  be  resumed 
it  is  limited  to  urethro-vesical  irrigation  with  mild 
and  warm  solutions  such  as  1:8000  permanganate  of 
potash  ;    but  it  is  a  safe  practice  to  rely  solely  on 


238    GONORRH(EA  &  ITS  COMPLICATIONS 

internal  medication  until  complete  subsidence  of  the 
epididymitis  has  been  secured.  Sitz  baths  twice  a 
day  are  of  considerable  value  ;  tincture  of  aconite 
and  antimonial  wine  are  old-time  favourites  now 
seldom  prescribed ;  opium  or  its  derivatives  may 
be  required  to  relieve  pain  and  induce  sleep  if 
phenacetine  is  not  sufficient  for  this  purpose. 
The  role  of  vaccines  in  epididymitis  is  con- 
sidered in  the  special  chapter  devoted  to  vaccine 
therapy. 

Operative  treatment. — Several  operative  measures 
have  been  advocated  with  the  object  of  aborting  the 
epididymitis  or  of  decreasing  the  liability  to  chronic 
nodular  infiltration.  Simple  puncture  was  practised 
by  Perigoff  in  1852,  Velpean  in  1854,  and  others. 
Henry  Smith  in  1864  pubhshed  in  the  "  Lancet  "  a 
report  of  several  cases  of  gonorrhoeal  orchitis  treated 
by  puncture  with  a  fine  bistoury.  On  account  of  septic 
complications  the  method  speedily  lost  favour,  and 
was  evidently  lost  sight  of  until  revised  in  a  m.odified 
form  by  Baermann  in  1903.  He  uses  a  glass  syringe 
with  a  fairly  large  needle,  and  punctures  the  whole 
length  of  the  epididymis.  During  withdrawal  he 
aspirates  with  the  syringe.  This  operation  gives  con- 
siderable relief  in  many  cases  by  reducing  tension, 
and  possibly  by  evacuating  small  abscess  cavities. 
Schindler  is  a  strong  advocate  of  this  measure.  He 
uses  a  needle  such  as  is  used  for  mercurial  injections. 
He  states  that  he  finds  the  operation  simple  and  but 
slightly  painful ;  that  pain,  tension,  and  fever  are 
immediately  relieved,  and  that  the  duration  of  the 
disease  is  reduced  by  half.  The  objection  to  this 
mode  of  treatment  is  the  risk  of  injury  to  the  fine 
canal  of  the  epididymis  and  consequent  sterility  on  the 
respective  side.    The  supporters  of  this  method  affirm 


GONOCOCCAL    EPIDIDYMITIS         239 

that  there  is  much  greater  risk  to  the  tube  from  the 
uncontrolled  inflammation  than  from  the  puncture. 
However,  it  is  necessary  to  consider  whether  the  bene- 
ficial effects  cannot  be  obtained  by  some  other  means 
while  avoiding  danger  to  the  continuity  of  the  canal. 
With  this  in  view,  Neisser  suggested  to  Bruck  the 
making  of  a  small  incision  (1  centimetre)  through  the 
coverings  of  the  epididymis  over  the  globus  minor. 
He  adopts  cocaine  infiltration  of  the  spermatic  cord 
only  in  occasional  cases.  The  scrotal  skin  is  disin- 
fected with  tincture  of  iodine,  and  the  incision  made 
with  a  fine-pointed  bistoury  for  a  distance  not  exceed- 
ing 1  centimetre.  While  pushing  the  affected  epi- 
didymis towards  the  knife  the  tunica  communis  and 
propria  are  slit  to  a  length  of  about  1  centimetre. 
The  wound  is  painted  with  tincture  of  iodine  and 
dressed  with  gauze  and  zinc  plaster.  Bruck  says  : 
"  The  effect  is  as  prompt  as  with  the  needle 
puncture,  the  epididymis  itself  is  not  hurt  or 
only  in  the  most  peripheral  parts,  and  no  com- 
plications have  ever  been  observed  to  follow  this 
procedin'c." 

This  simple  operation  seems  to  require  slight  modi- 
fication to  avoid  if  possible  the  risk  of  injury  to  the 
"  most  peripheral  parts  "  of  the  epididymis.  For 
instance,  a  minute  superficial  incision  might  be  made 
in  the  fibrous  coat  of  the  epididymis,  just  suffi- 
cient to  allow  of  the  insertion  of  a  small  director  on 
which  the  further  incision  of  the  capsule  might  be 
made  ;  or  a  small  pair  of  scissors  might  be  used  for 
the  purpose  with  less  risk  of  injury  to  the  essential 
structure  of  the  organ,  the  convoluted  canal  of  the 
epididymis. 

Injection  of  a  colloidal  silver  preparation,  "  Elec- 
trargol,"   into   the   substance   of   the   epididymis   is 


240    GONORRHCEA  &  ITS  COMPLICATIONS 

recommended  by  Asch.  He  uses  a  fine  needle  and 
injects  -5  to  1  cubic  centimetre  of  an  isotonic  solution  of 
an  electrically  prepared  silver  colloid.  It  has  usually 
been  found  that  in  addition  to  the  pain  of  the  punc- 
ture the  instillation  of  the  fluid,  by  increasing  the 
tension,  causes  a  marked  increase  in  the  pain  for  one 
or  two  hours.  Thereafter  the  course  of  the  acute 
stage  is  modified  for  the  better,  but  the  ultimate 
result  as  regards  permanent  infiltration  is  even  less 
satisfactory  than  when  purely  expectant  treatment 
is  adopted. 

Epididymotomy. — More  extensive  surgical  inter- 
ference was  suggested  by  Belfield  in  1905  in  an  article 
entitled  "  Pus  Tubes  in  the  Male."  He  advised  an 
incision  one  inch  long  into  the  epididymis  and  the 
suturing  of  the  skin  and  tunica  edges  together.  In 
1906  Bazet  reported  several  cases  operated  on 
during  the  previous  nine  years.  He  cut  down  on 
the  epididymis  along  the  line  of  the  ligamentum 
scrotale,  thus  avoiding  the  cavity  of  the  tunica 
vaginalis. 

In  the  same  year  Hagner  independently  elaborated 
an  operation  for  severe  cases  of  epididymitis,  for 
which  he  has  now  gained  wide  acceptance  in  the 
United  States.  Much  of  our  knowledge  of  the  path- 
ology of  the  condition  is  due  to  Hagner's  work.  He 
states  that  visible  pus  was  present  in  80  per  cent  of 
his  cases,  but  in  this  connection  it  should  be  remem- 
bered that  he  only  operates  on  the  more  acute  cases. 
Describing  his  technique,  Hagner  says  :  "  At  a  point 
over  the  juncture  of  the  epididymis  and  testicle  an 
incision  6  to  10  centimetres  long  is  made  through  the 
skin  and  parietal  layer  of  the  tunica  vaginalis.  After 
the  serous  membrane  is  opened  all  the  fluid  is  evacu- 
ated and  the  enlarged  epididymis  examined  through 


GONOCOCCAL   EPIDIDYMITIS         241 

the  wound.  The  testicle,  with  its  adnexa,  is  dehvered 
from  the  tunica  vaginahs  and  enveloped  in  warm 
towels.  The  epididymis  is  then  examined  and  mul- 
tiple punctures  made  through  its  fibrous  covering 
with  a  tenotome,  especially  over  those  portions  where 
the  enlargement  and  thickening  is  greatest.  The 
knife  is  carried  deep  enough  to  penetrate  the  thickened 
fibrous  capsule  and  enter  the  infiltrated  connective 
tissue.  When  the  knife  is  through  the  thickened 
covering  of  the  epididymis  a  very  marked  lessening 
of  resistance  will  be  felt.  If  pus  is  seen  to  escape 
from  any  of  the  punctures,  the  opening  is  enlarged 
by  incising  the  connective  tissue  covering  the  epi- 
didymis, care  being  taken  not  to  wound  the  tubules. 
A  small  probe  is  inserted  from  which  the  pus  flows, 
then  by  a  backward  and  forward  motion  of  the  probe 
the  opening  is  enlarged  and  the  pus  allowed  to  escape. 
By  this  method  I  believe  there  is  less  danger  of  in- 
juring the  tubes  of  the  epididymis  than  by  cutting 
with  a  knife.  After  the  probe  has  been  passed  in  pus 
will  be  evacuated  by  light  massage  in  the  region  of 
the  abscess,  and  a  finely  pointed  syringe  is  used  in 
washing  out  the  cavity  with  a  1:1000  bichloride  of 
mercury,  followed  by  a  physiological  salt  solution. 
The  testis  is  then  restored  to  its  normal  position,  and 
in  every  case  the  tunica  vaginalis  is  thoroughly 
washed  with  1:1000  bichloride,  followed  by  normal 
salt  solution.  The  incision  of  the  tunica  vaginalis  is 
lightly  closed  with  a  running  catgut  suture ;  a 
cigarette  drain  of  gauze  is  then  passed  through  the 
lower  angle  of  the  incision  in  the  tunica  vaginalis 
down  to  the  epididymis,  the  skin  being  brought  to- 
gether by  a  subcutaneous  silver-wire  suture,  the 
cigarette  drain  passing  out  at  the  lower  angle  of  the 
wound.     Silver  foil  and  a  sterile  dressing  are  now 

WATSON. — R 


242    GONORRHCEA  &  ITS  COMPLICATIONS 

applied  and  the  part  supported  by  a  T  bandage  or 
suspensory." 

The  relief  of  pain  is  complete  and  immediate 
following  this  operation.  Its  supporters  maintain 
that  the  duration  of  the  disease  is  reduced,  and  the 
ultimate  results  more  satisfactory,  especially  as  re- 
gards occlusion  of  the  canal  and  sterihty.  If  therefore 
all  risk  of  sepsis  could  be  entirely  eliminated  there 
would  be  much  to  recommend  this,  the  most  heroic 
of  the  surgical  methods  of  dealing  with  the  acute  type 
of  epididymitis. 

Epididymo-vasotomy. — For  the  cure  of  sterility 
dependent  on  chronic  nodular  infiltration  or  perma- 
nent occlusion  of  the  canals  of  both  epididymes  from 
any  other  cause,  Martin  has  introduced  an  opera- 
tion which  has  met  with  considerable  success  in 
selected  cases.  It  is  an  attempt  to  procure  an 
anastomosis  between  the  epididymis  at  a  point 
above  the  site  of  the  constriction  and  the  vas 
(epididymo-vasotomy). 

Cases  are  only  ready  for  operation  when  the  rest  of 
the  genital  tract  has  been  cleared  of  obstruction  and 
infection.  Martin  recommends  that  the  surgeon 
should  assure  himself  of  the  patency  of  the  vas  by 
the  preliminary  performance  of  Belfield's  operation, 
using  twenty  to  thirty  drops  of  a  watery  solution  of 
an  inert  colouring  matter  ;  the  vesicle  and  ampulla 
are  massaged  and  the  colour  should  then  show  in  the 
urine.  Another  necessary  precaution  is  to  demon- 
strate the  presence  in  the  fluid  removed  from  the 
testicle  by  a  hypodermic  syringe  of  normal  motile 
spermatozoa.  The  anastomosis  is  obtained  by  sutur- 
ing together  the  edges  of  an  oblique  incision  in  the 
vas  at  the  level  of  the  head  of  the  epididymis  directly 
to  an  oval  opening  made  in  the  globus  major.    The 


GONOCOCCAL   EPIDIDYMITIS         243 

epididymis  is  approached  from  a  posterior  scrotal  in- 
cision, and  if  the  veins  are  carefull}^  avoided  Httle 
or  no  haemorrhage  may  be  anticipated. 

Belfield's  operation,  mentioned  above,  was  sug- 
gested for  irrigation  and  drainage  of  the  seminal  duct 
and  vesicle  through  the  vas  deferens.  The  vas  is 
isolated  by  the  fingers  from  the  other  structures  of 
the  spermatic  cord,  pressed  against  the  scrotal  skin 
and  fixed  by  passing  a  curved  needle  behind  it. 
Under  local  anaesthesia,  a  half-inch  incision  is  made 
through  the  skin  and  coverings  of  the  spermatic 
cord,  the  vas  is  exposed,  and  a  small  opening  is 
made  into  the  canal.  A  blunted  hypodermic  needle 
will  pass  into  this  minute  channel,  and  a  watery  solu- 
tion, to  the  extent  of  20  or  30  minims,  of  any  desired 
agent  may  be  injected.  The  fluid  will  pass  along 
the  vas  and  distend  the  seminal  vesicles.  To  main- 
tain a  fistula  for  continued  treatment,  the  edges  of 
the  vas  incision  may  be  stitched  to  the  skin  wound. 

Belfield  states  that  by.  this  method  not  only  can 
chronic  infection  of  the  vesicles  be  rationally  treated, 
but  an  impending  epididymitis  may  be  aborted  or 
recurring  attacks  prevented.  The  wound  is  closed 
by  suture  when  healing  is  desired. 

Speaking  generally  of  surgical  interference  in  epi- 
didymitis, it  can  require  consideration  in  but  a  small 
proportion  of  cases,  and  should  only  be  ultimately 
adopted  in  a  selected  few.  Operative  treatment 
should  not  be  lightly  undertaken  in  a  condition  which 
tends  to  spontaneous  cure,  where  aseptic  surround- 
ings are  difficult  to  procure  and  maintain,  where  anti- 
septics, on  account  of  the  sensitiveness  of  the  scrotal 
skin,  have  to  be  employed  cautiously,  and  where 
exact  procedure  is  impossible  on  account  of  the  fine- 
ness of  the  convoluted  canal. 


244    GONORIIHCEA  &  ITS  COMPLICATIONS 

It  is  evident  that  more  harm  than  good  may 
follow  haphazard  interference,  and  that  operation  in 
any  given  case  should  only  be  undertaken  after  care- 
ful consideration,  but  nevertheless  surgery  has  here 
a  legitimate,  if  limited,  field  of  usefulness. 


m 


CHAPTER    XIV 

GONORRHCEA   IN   THE   FEMALE 

Important  as  gonorrhoea  in  the  male  undoubtedly 
is,  gonorrhoea  in  the  female  is  even  more  serious  as 
regards  its  remote  effects.  The  anatomical  arrange- 
ment of  the  female  genito-urinary  tract  favours 
the  upward  growth  of  the  gonococcus  by  continuity 
of  surface.  The  monthly  recurrence  of  menstruation 
and  also  the  puerperal  state  are  propitious  periods 
for  further  extension  of  gonorrhoea!  infection,  and  it 
is  following  these  conditions  that  an  acute  attack 
of  tubo-ovarian  or  pelvic  inflammation  frequently 
asserts  itself. 

AATiile  the  surgical  aspects  of  some  of  the  effects  of 
gonorrhoeal  infection  of  the  genito-urinary  tract  bulks 
largely  in  modern  text-books  of  gynaecology,  the 
subject  is  seldom  approached  in  its  proper  sequence, 
and  practically  never  in  its  proper  perspective.  The 
older  text-books  devoted  insufficient  space  to  gonor- 
rhoea in  the  male,  but  absolutely  insignificant  space 
to  the  same  disease  in  the  female.  This  neglect  was 
largely  due  to  the  difficulty  of  differentiating  between 
what  was  thought  to  be  leucorrhoea  and  the  true  in- 
fective gonorrhoea,  as  well  as  failure  to  appreciate  its 
significance  as  a  cause  of  pelvic  inflammation.  The 
discovery  of  the  gonococcus  was  not  immediately 
followed  by  a  marked  change  in  this  respect,  owing  to 
the  greater  difficulty  experienced  in  isolating  the 
organism  from  the  discharge  of  female  patients. 

■2i5 


246    GONOERHCEA  &  ITS  COMPLICATIONS 

West,  Bernutz,  and  Goupil  about  the  middle  of 
the  last  century  made  passing  reference  to  gonorrhoea 
as  a  possible  cause  of  tubal  and  pelvic  inflammation, 
but  little  notice  was  taken  of  the  suggestion  by  subse- 
quent authors.  West  (1856),  speaking  of  the  upward 
spread  of  gonorrhoeal  inflammation,  says  :  "  The 
tendency  of  inflammation  of  the  uterine  mucous 
membrane  to  extend  along  the  Fallopian  tubes  and 
to  attack  the  peritoneum  is  much  stronger  than  to 
affect  the  substance  of  the  organ,  and  although 
abscesses  sometimes  form  as  a  secondary  result  of 
the  disease,  they  are  almost  always  situated  in  the 
pelvic  cellular  tissue  or  within  the  folds  of  the  broad 
ligament,  and  scarcely  ever  in  the  interior  wall  itself." 

Much  discussion  has  ranged  round  the  question 
of  the  incidence  of  gonorrhoea  in  women,  and  also  as 
to  the  comparative  frequency  of  its  occurrence  in 
women  as  compared  with  men. 

Noeggerath  in  1872  wrote  forcibly  on  this  subject, 
and  provoked  a  storm  of  discussion.  His  work  was, 
of  course,  unsupported  by  bacteriological  proof,  and  he 
considerably  overstated  his  case.  He  postulated  that 
80  per  cent  of  men  acquired  at  least  one  acute  attack  of 
gonorrhoea,  that  gonorrhoea  was  an  incurable  disease, 
and  that  the  wives  of  these  men  invariably  became 
infected.  He  concluded  therefore  that  approximately 
the  same  percentage  of  women  as  of  men  were  the 
subjects  of  gonorrhoeal  infection.  WTiile  much  of  the 
pioneer  work  which  Noeggerath  accomplished  on  the 
subject  of  chronic  gonorrhoea  is  now  the  accepted 
teaching,  it  is  recognised  that  his  estimate  of  the 
frequency  of  gonorrhoea  in  women  was  excessive, 
but  so  much  discrepancy  still  occurs  in  the  estimates 
of  different  observers  that  little  purpose  can  be 
served  by  reproducing  them  here.     Suffice  it  to  say 


GONOKRHCEA   IN   THE   FEMALE      247 

that  while  there  is  not  the  same  latitude  for  increased 
incidence  among  males,  the  percentage  of  affected 
females  is  steadily  increasing,  and  is  likely  to  continue 
to  do  so  until  the  question  receives  the  serious  con- 
sideration and  attention  from  the  State  which  its 
gravity  demands. 

Anatomical  data. — Only  such  anatomical  and 
physiological  questions  as  have  some  bearing  on  the 
progress  of  gonorrhoeal  infection  will  be  considered. 

The  urethra  in  the  female  is  a  musculo-membranous 
canal,  3  centimetres  in  length  and  7-8  millimetres  in 
diameter.  So  elastic  are  the  walls  that  it  can  by 
gradual  dilatation  be  distended  to  2-5  centimetres  or 
more,  admitting  of  the  index  finger  without  incon- 
tinence of  urine  resulting.  The  walls  are  0-5  centi- 
metre in  thickness.  From  the  internal  or  vesical 
orifice  the  urethra  passes  through  the  bladder  wall 
(intramural  portion),  runs  a  short  course  (the  superior 
or  free  portion)  until  it  enters  the  vaginal  wall  (the 
inferior  or  vaginal  portion)  and  terminates  at  the 
external  or  vestibular  orifice.  Except  during  urina- 
tion the  walls  are  in  apposition.  The  mucous  mem- 
brane is  thrown  into  longitudinal  folds  so  that  a 
transverse  section  shows  a  stellate  closure.  These 
ridges  are  not  entirely  obliterated  by  distension  of 
the  urethra,  one  fold  in  particular  being  prominent 
on  the  lower  or  posterior  wall.  The  epithelial  lining 
is  of  the  stratified  squamous  variety,  but  towards  the 
bladder  it  becomes  transitional.  It  is  pierced  by 
numerous  lacunae  and  also  by  tubular  glands,  which 
secrete  a  colloid  material,  and  are  homologues  of  the 
prostatic  tubules.  These  are  especially  numerous  in 
the  region  of  the  external  meatus,  where  a  group  on 
each  side  empties  into  a  special  efferent  duct  (Skene's 
ducts).      These  ducts  vary  in  length  from  1-2  centi- 


248    GONORRH(EA  &  ITS  COMPLICATIONS 

metres,  and  lie  beneath  the  mucous  membrane  in 
the  muscular  coat.  They  run  parallel  to  the  long 
axis  of  the  urethra,  and  their  orifices  will  be  found 
to  be  2-3  millimetres  inside  the  external  meatus, 
unless  the  latter  should  be  patulous,  in  which  case 
the  openings  of  the  ducts  may  be  seen  on  each  side 
of  the  urethra  on  separating  the  labia.  They  are 
sufficiently  large  to  admit  of  the  passage  of  a  number 
one  probe  (French  scale).  The  distal  ends  of  these 
ducts  may  divide  into  several  branches. 

The  mucous  membrane  of  the  vulva  is  covered  by  a 
scaly  epithelium,  and  is  provided  with  numerous 
mucous  crypts  or  follicles  as  well  as  a  large  number 
of  sebaceous  and  other  glands. 

The  glands  of  Bartholin  correspond  to  Cowper's 
glands  in  the  male.  They  measure  from  1-2  centi- 
metres in  their  longest  diameter,  and  their  ducts 
open  one  on  each  side  of  the  vaginal  introitus  in  the 
groove  between  the  attached  border  of  the  hymen 
and  the  labium  minus. 

The  mucous  membrane  of  the  vagina  is  covered  by 
stratified  scaly  epithelium,  and  possesses  great  num- 
bers of  microscopic  papillae,  but  only  exceptionally 
any  glands. 

The  mucous  membrane  of  the  cervix  is  closely  ad- 
herent to  the  subjacent  tissue,  and  is  sharply  defined 
from  that  of  the  body  of  the  uterus.  In  the  lower 
portion  of  the  cervical  canal  the  epithelium  retains 
the  characteristics  of  the  vaginal  mucosa,  being  of 
the  stratified  squamous  variety  and  possessing  no 
glands.  In  the  upper  portion  the  epithelial  layer 
is  ciliated,  and  is  pierced  by  the  ducts  of  numerous 
tubular  and  acinous  glands. 

The  mucous  membrane  of  the  uterus  is  a  soft  spongy 
stratum,    1    millimetre   thick   in   the   intermenstrual 


GONORRHOEA    IN   THE   FEMALE      249 

period.  It  is  covered  by  a  layer  of  columnar  ciliated 
epithelium,  and  contains  many  long  convoluted  tubu- 
lar glands,  which  extend  throughout  its  whole  thick- 
ness, and  sometimes  penetrate  between  the  fibres  of 
the  subjacent  muscular  tissue.  These  glands  are  also 
lined  with  ciliated  epithelium. 

According  to  Young,  the  uterine  mucosa  is  a  soft 
protoplasmic  mass  imperfectly  differentiated  into 
cellular  elements.  The  supporting  network  consists  of 
branching  cell  processes,  and  these  are  more  of  the 
nature  of  films  than  filaments.  The  blood-vessels 
are  constructed  of  flattened  stroma  cells  unsup- 
ported, except  in  the  deepest  layers,  with  any 
specialised  coats. 

This  "  structural  peculiarity,"  says  Young,  "  is 
obviously  designed  for  the  purpose  of  permitting  with 
the  greatest  possible  efficiency  an  immediate  flushing 
of  any  part  of  the  stroma  with  a  plentiful  supply  of 
blood." 

Menstrual  changes. — Preceding  the  onset  of  men- 
struation there  is  formed  in  the  protoplasm-  of  the 
mucosa  a  colloidal  or  crystalloidal  substance  which 
has  an  active  affinity  for  fluids.  The  resulting  im- 
bibition of  fluid  from  the  blood-stream  produces  an 
acute  engorgement  of  the  tissue  with  oedematous  in- 
filtration :  the  cells  of  the  blood-tracts  are  separated, 
and  the  way  is  prepared  for  the  escape  of  blood-cells 
and  plasma.  These  changes  are  under  ovarian  con- 
trol, and  are  probably  due  to  some  bio-chemical 
substance  of  ovarian  origin  (secretion  or  hormone) 
which  reaches  the  uterus  through  the  blood-vessels. 

Bland  Sutton,  from  an  examination  of  human 
uteri  during  menstruation,  found  that  there  was 
desquamation  only  of  small  and  superficial  areas  of 
the  epithelial  lining.     Stephenson  has  demonstrated 


250    GONORRHCEA  &  ITS  COMPLICATIONS 

a  cycle  of  metabolic  phenomena  associated  with  the 
menstrual  flow.  For  one  to  two  days  preceding  men- 
struation there  is  an  average  rise  of  half  a  degree  in 
the  temperature,  the  excretion  of  urea  reaches  its 
maximum,  the  pulse  rate  is  accelerated  and  the 
arterial  tension  is  increased.  During  the  period  there 
is  a  return  to  the  normal,  and  following  the  cessation 
of  menstruation  a  subnormal  level  is  reached. 

Early  in  the  menstrual  period  there  is  a  general 
turgescence  of  the  pelvic  organs,  but  as  the  flow 
becomes  established  the  vascularity  diminishes,  the 
uterus  softens,  and  the  cervix  dilates. 

The  Fallopian  tubes  communicate  with  the  cavity 
of  the  uterus  through  very  minute  orifices,  which  in 
the  normal  condition  will  hardly  admit  of  the 
passage  of  a  bristle.  The  mucosa  of  the  tube  is  lined 
with  ciliated  epithelium,  the  cilia  acting  in  the  direc- 
tion of  the  uterus.  The  mucous  membrane  is  thrown 
into  a  series  of  longitudinal  folds,  which  are  obliterated 
on  distension  of  the  tube. 

The  lymphatics  of  the  vagina  drain,  according  to 
Waldeyer,  in  three  directions.  Those  of  the  lower 
section  join  with  the  lymphatics  of  the  vulva  in 
passing  to  the  inguinal  glands  ;  the  middle  portion 
is  connected  with  the  glands  of  the  hypogastrium, 
and  the  plexus  of  the  upper  part  unite  with  the 
lymphatics  from  the  uterus,  which  pass  through  the 
broad  ligament  to  the  external  iliac  glands. 

The  secretion  of  the  uterus  is  slightly  alkaline  in  re- 
action, and  contains  a  considerable  amount  of  mucus 
derived  from  the  cervical  and  uterine  glands. 

The  vagina  being  without  glands  secretes  merely  a 
serous  fluid  containing  some  leucocytes  and  epithelial 
debris.  In  reaction  it  is  acid  (-945  per  cent),  and  it 
gains  this  property  from  the  lactic  acid  activity  of  the 


GONORRHCEA   IN   THE   FEMALE      251 

bacillus  of  Doderlein.  Zweifel  suggests  that  in  addi- 
tion to  the  free  lactic  acid  in  the  vagina,  there  is  a 
proportion  in  combination  with  a  base  probably 
sodium.  Antiseptics  decrease  the  acidity  by  destroy- 
ing or  inhibiting  the  vaginal  bacilli.  Doderlein  and 
Zweifel  point  out  that  in  douching  with  tap  water  the 
lactic  acid  becomes  fixed  by  combining  with  the 
bases  in  the  water,  while  following  the  use  of  distiUed 
water  the  lactic  acid  is  rather  increased. 

During  menstruation  and  also  during  the  puer- 
perium  this  acidity  is  lessened  if  not  abolished,  and 
infection  of  the  uterine  cavity  is  therefore  more 
prone  to  occur  at  these  periods.  Any  condition  of 
health  which  markedly  increases  the  uterine  and 
vaginal  secretion  and  thus  produces  dilution  of  the 
acid  content  of  the  vagina  is  also  a  factor  favourable 
to  the  spread  of  infective  processes.  A  slow  stream 
conduces  to  the  formation  of  acid  and  vice  versa. 

Clinical  signs  of  gonorrhoea  in  the  female. — The 
symptoms  of  the  onset  of  gonococcal  infection  in 
women  are  in  many,  probably  most,  cases,  not  such 
as  to  cause  much  inconvenience,  and  only  in  a  small 
percentage  of  cases  is  the  patient  impelled  to  seek 
medical  advice  in  the  early  stages  of  the  disease. 

In  women  of  cleanly  habits  the  discharge  usually 
gives  rise  to  but  little  irritation,  and  vaginal  discharge 
is  of  such  common  occurrence  that  it  attracts  little 
attention,  especially  when  an  antiseptic  douche  is 
part  of  the  toilet ;  for  although  douching  is  valueless 
as  regards  reduction  of  infectivity  or  as  a  preventa- 
tive of  upward  extension  of  the  disease,  it  controls 
the  gross  symptoms.  Some  cases,  however,  run  an 
acute  course  from  the  beginning,  and  the  inflamma- 
tory reaction  may  be  so  severe  as  to  confine  the 
patient  to  bed.     This  type  is  most  common  in  un- 


252    GONORRHGEA  &  ITS  COMPLICATIONS 

married  girls  and  in  newly  married  or  in  pregnant 
women. 

The  parts  most  subject  to  primary  gonococcal  in- 
flammation are,  first,  the  cervix ;  second,  the  ure- 
thra ;    and,  third,  the  Bartholin  glands. 

The  cervix  is  of  outstanding  importance  as  an 
original  site  of  the  disease.  It  is  inoculated  in  nearly 
all  infections  of  adults,  and  in  the  few  cases  in  which 
the  urethra  is  infected  in  the  first  instance,  the 
cervix  is  soon  implicated  and  becomes  the  main 
source  of  danger.  The  picture  presented  by  a  re- 
cently infected  cervix  is  one  of  acute  catarrhal  in- 
flammation. The  mucous  membrane  is  swollen  and 
dull  red.  Pus  is  seen  exuding  from  the  os  externum. 
The  cervix  bleeds  readily,  and  the  manipulation 
necessary  in  examining  causes  pain. 

The  vagina  is  not  a  locus  of  gonococcal  activity,  but 
it  becomes  irritated  and  sometimes  inflamed  by  the 
action  of  the  gonococcic  secretion  pouring  over  it  from 
the  cervix.  The  vaginal  secretion  is  increased,  the 
vaginal  bacillus  inhibited,  and  the  lactic  acid  reaction 
reduced. 

The  vulva,  like  the  vagina,  is  affected  by  the  irri- 
tating properties  of  the  discharge  and  may  become 
inflamed  and  oedematous.  The  labia  minora  and  the 
clitoris  may  be  much  inflamed,  and  a  permanent 
hypertrophy  may  result. 

Para-urethral  passages  are  of  frequent  occurrence 
in  the  female,  as  also  are  blind  pockets  on  the  inner 
vulvar  surfaces.  One  very  constant  pocket  is  found 
on  each  side  of  the  urethra  close  to  the  smaller  labial 
fold.  These  passages  and  pockets,  as  well  as  the 
ducts  of  any  of  the  vulvar  glands,  may  become  in- 
fected, and  if  overlooked,  they  may  remain  the  source 
of  a  chronic  infection.    Wren  implicated,  the  orifices 


PLATE  X. 


l_0-,-o-ri,-,,  'p^-t-^ 


Urethritis  and  Bartholinitis. 


On  retracting  the  labia,  ttie  external  urinary  meatus  appears  as  a  reddened, 
elevated  area.  The  mucosa  is  thickened  and  more  or  less  everted.  This  is 
especially  noticed  in  the  labia  of  the  urethra.  The  exit  to  Bartholin's  gland  on 
the  right  side  is  reddened,  and  presents  the  typical  appearance  of  a  gonococcal 
macule.  A  small  drop  of  pus  is  seen  exuding.  As  a  result  of  the  irritating 
discharge,  the  vulvar  orifice  is  seen  to  be  more  or  less  inflamed.  The  infection 
of  the  crypts  about  the  urethra  is  well  illustrated.      [Norris.] 


GONORRHCEA    IN   THE    FEMALE      253 

appear  as  minute  reddened  spots  projecting  slightly 
beyond  the  mucous  surface.  The  glands  are  fre- 
quently involved  in  groups,  when  a  small  patch  of 
redness  will  indicate  the  area  requiring  special  treat- 
ment. 

The  glands  of  Bartholin  are  frequently  affected. 
The  orifices  of  their  ducts  will  then  appear  as  two 
reddened  areas  lying  in  the  grooves  between  the 
attached  borders  of  the  hymen  and  the  posterior 
extremities  of  the  labia  minora.  A  cystic  abscess 
may  be  induced  by  inflammatory  closure  of  the  duct. 

The  urethra  is  inoculated  sooner  or  later  in  the 
majority  of  cases  (80  per  cent).  The  urethritis  is 
rarely  so  acute  as  to  cause  much  discomfort.  Even 
when  pus  is  seen  exuding  from  the  urethra  and  the  lips 
of  the  meatus  are  coated,  oedematous,  and  reddened, 
there  may  be  no  difficulty  in  voiding  urine  nor  sensa- 
tion of  scalding.  There  is,  however,  some  tenderness 
on  pressure,  and  therefore  coitus  is  painful. 

In  order  to  see  the  appearance  of  a  urethritis  at 
its  worst,  the  patient  must  be  advised  to  refrain  from 
micturition  and  from  cleansing  the  parts  in  any  way 
for  some  time  previous  to  the  examination.  The 
neglect  of  this  precaution  explains  why  the  disease 
in  the  urethra  is  so  frequently  overlooked. 

\Mien  the  meatus  looks  normal  and  no  pus  presents 
there,  it  may  be  possible  by  digital  pressure  along  the 
course  of  the  urethra  in  the  anterior  vaginal  wall  to 
express  a  droplet  of  pus.  ^^Tien  the  secretion  is 
scanty,  as  in  the  later  stages  of  a  urethritis,  the  only 
obtainable  evidence  of  urethral  infection  will  be  from 
microscopic  examination.  Routine  examination  of 
urethral  smears  is  necessary  as  a  guide  to  treatment, 
and  when  this  has  been  carried  out  in  a  series  of  cases 
the  urethra  has  been  found  to  be  affected  in  over 


254    GONORRHCEA  &  ITS  COMPLICATIONS 

80  per  cent  of  cases.  The  comparative  freedom  of  the 
urethra  from  acute  inflammation  is  due  to  the  nature 
of  its  epithehal  hning  (squamous  and  transitional). 
The  main  sites  of  urethral  infection  are  its  glands  and 
also  Skene's  ducts,  whose  minute  openings  are  found 
just  within  the  meatus  at  the  junction  of  the  posterior 
third  with  the  anterior  two-thirds  of  the  urethral 
wall. 

Gonorrhoeal  cystitis  is  not  a  common  condition. 
The  bladder  epithelium  resists  the  gonococcus,  and 
unless  its  powers  are  reduced  by  injury  or  disease 
it  can  do  so  effectively.  Certain  small  areas  in  the 
trigone  are  the  parts  affected  when  a  cystitis  is  es- 
tablished, and  these  are  seen  through  the  cystoscope 
as  minute  red  patches  raised  slightly  above  the 
surface  of  the  surrounding  healthy  membrane.  Gono- 
cocci  can  be  obtained  by  swabbing  these  patches,  and 
the  nature  of  the  lesion  can  thus  be  demonstrated. 

The  presence  of  the  gonococcus  in  urinary  sediment 
is  not  conclusive  of  gonorrhoeal  cystitis,  but  if  large 
numbers  of  gonococci  are  found,  probably  a  "  urethro- 
cystitis "  is  the  underlying  condition,  the  urethra 
with  the  above-mentioned  areas  in  the  adjacent 
trigone  being  involved  in  one  inflammatory  process. 

The  ureters,  like  the  bladder,  are  not  prone  to 
attack,  but  several  cases  of  kidney  involvement  have 
been  reported. 

MODE   OF   INFECTION    IN    THE    FEMALE 

The  usual  mode  of  infection  in  the  female  is  by 
direct  transference  of  the  infection  to  the  genital 
canal  during  coition,  but  cases  in  which  indirect  in- 
fection is  responsible  for  the  onset  of  gonorrhoea  are 
also  found  in  practice. 


GONORRHCEA   IN    THE   FEMALE      255 

Direct  infection  may  be  incurred  from  {a)  a  case  of 
acute  gonorrhoea,  or  (h)  a  case  of  chronic  or  recurring 
gonorrhoea.  Most  cases  of  infection  in  the  female 
are  caused  by  contagion  from  an  apparently  cured 
male.  This  is  what  so  frequently  occurs  in  early 
married  life.  The  husband,  presenting  no  symptoms 
of  his  former  disease,  seeks  and  obtains  permission  to 
marry  from  a  physician,  or  relying  on  his  own  observa- 
tions enters  matrimony  with  an  altogether  false 
sense  of  security.  It  cannot  be  too  strongly  empha- 
sised that  a  grave  responsibility  rests  on  the  medical 
profession  with  regard  to  such  cases.  Some  of  the 
most  expert  and  experienced  specialists  admit  having 
wrongly  consented  to  marriage  with  disastrous  re- 
sults, and  they  have  therefore  increased  the  scope  of 
their  inquiry  and  the  thoroughness  of  their  investi- 
gations. 

No  man  who  has  suffered  from  gonorrhoea  should 
marry  until  careful  and  repeated  microscopic  examina- 
tions prove  the  continued  absence  of  the  gonococcus 
from  the  anterior  and  posterior  urethrse  and  from  the 
adnexse.  In  many  cases  it  will  be  necessary  to  adopt 
some  of  the  methods  which  stimulate  any  latent 
organisms  which  may  be  lurking  in  the  glands  or 
tissues  into  activity.  Otherwise  marriage  itself  may 
succeed  in  doing  so,  and  a  recrudescence  of  the 
disease  occur  with  more  or  less  reappearance  of 
symptoms  and  an  inevitable  infection  of  the  wife. 

The  gravity  of  this  question  is,  in  this  country, 
not  understood  by  the  public  and  insufficiently  ap- 
preciated by  the  medical  profession.  The  "  horrors  " 
of  such  a  situation  require  no  writing  up.  Once  any 
man  realises  that  he  is  a  potential  source  of  actual 
and  real  danger  he  will  surely  leave  no  means  untried 
to  cleanse  himself  from  the  last  traces  of  this  disease. 


256    GONORRHCEA  &  ITS  COMPLICATIONS 

And  now  the  medical  profession  is  called  on  to  under- 
take what  may  prove  a  difficult  and  tedious  task. 
But  cure  can  be  attained  in  the  end,  and  nothing  less 
than  complete  success  in  the  eradication  of  the 
gonococcus  can  satisfy. 

Indirect  infection,  while  it  occurs  in  but  a  small 
percentage  of  the  total  cases,  is  not  uncommon  in 
practice,  and  it  is  not  of  such  rare  appearance  as  to 
be  received  with  complete  scepticism  as  an  explana- 
tion of  the  occurrence  of  a  gonorrhoea.  The  usual 
modes  by  which  indirect  infection  is  conveyed  in- 
clude (a)  infected  towels  or  linen,  {h)  water-closet 
seats  or  water,  (c)  instruments  or  douche  nozzles,  (d) 
hands. 

In  all  public  lavatories,  the  water-closet  seats 
should  be  made  with  an  intervening  gap  of  a  few 
inches  in  its  most  anterior  section. 

Douche  nozzles  should  be  personal,  and  this  should 
be  ensured  by  their  being  kept  under  lock  and  key.  No 
laxity  in  the  sterilization  of  gynaecological  instruments 
should  be  tolerated.  Actions  for  substantial  damages 
have  been  successfully  raised  in  America  against 
physicians  for  carelessness  in  this  respect,  and  the 
fact  that  none  have  been  reported  in  this  country  so 
far  is  not  for  want  of  cases.  Usually  attention  is  first 
drawn  to  such  a  case  by  the  infection  of  the  husband. 

CO-EXISTENCE  OF  OTHER  ORGANISMS  WITH  THE 
GONOCOCCUS  IN  THE  FEMALE  GENITO-URINARY 
TRACT 

In  speaking  of  the  bacteriology  of  gonorrhoea  in 
the  female,  reference  was  made  to  the  numbers  of 
other  germs  seen  in  smears,  and  a  description  of  the 
commonest  of  these  has  already  been  given.  The 
relative  importance  of  these  contaminating  organisms 


GONORRHCEA    IN   THE    FEMALE      257 

in  the  production   of  inflammatory    processes    is    a 
question  of  much  practical  interest. 

Menge  very  ably  supports  the  view  that  they  are 
for  the  most  part  saprophytes  living  in  the  exudation 
and  not  in  the  tissues.    He  denies  that  the  gonococcus 
will  tolerate  the  growth  of  any  other  organism  along- 
side its  own  colonies,  and  affirms  that  the  toxin  of 
the  gonococcus,  if  in  sufficient  concentration,  destroys 
other  bacteria,  and  that  there  is  always,  therefore, 
an  appreciable  distance  between  the  fields  of  gonococci 
and  those  of  any  other  coexisting  organisms.    Menge 
speaks  of  a  "  fighting  zone  "  above  which,  in  gonor- 
rhoeal  disease,  the  gonococcus  exists  in  pure  culture. 
He  places  this  in  the  case  of  the  urinary  tract  just 
within  the  meatus  of  the  urethra,  and  in  the  case  of 
the  genital  tract  of  adults  just  within  the    cervix. 
Contamination    of   smears    and   of   cultures    is    with 
difficulty  avoided,  owing  to  the  presence  of  numerous 
pyogenic  and  other  organisms  at  the  entrance  both 
of  the  urethra  and  cervix,  but  if  stringent  measures 
are  taken  to  avoid  the  possibility  of  admixture  with 
these  extraneous  organisms,  gonocooci  alone,  accord- 
ing to  Menge,  will  in  almost  all  cases  be  demonstrated. 

The  expressions  "  mixed  infection  "  and  "  secondary 
infection  "  have  certainly  been  somewhat  loosely  em- 
ployed ;  and  as  Menge  has  elaborated  a  very  com- 
plete classification,  which  includes  all  the  methods  in 
which  other  germs  can  complicate  gonorrhoeal  inflam- 
mation, I  have  accepted  it  with  acknowledgment  of 
Menge's  success  in  so  far  maintaining  the  truth  of  his 
views,  although  unable  to  follow  him  to  his  ultimate 
conclusions. 

Classifications  of  bacterial  infections  in  the  female 
(Menge)  : — 

An  infection  is  a  disease  of  the  organism  produced 


258    GONORRHCEA  &  ITS  COMPLICATIONS 

and  maintained  by  the  penetration  of  parasitic  micro- 
organisms into  the  Hving  tissue. 

Simple  infection  is  one  in  which  only  a  single 
species  of  micro-organism  is  present  in  the  tissues. 

In  mixed  infections,  on  the  other  hand,  two  or  more 
varieties  of  parasites  are  involved  in  producing  disease 
in  the  same  tissue  regions. 

It  is  not  permissible  to  distinguish  as  an  infection 
a  condition  in  which  there  is  saprophytic  growth  of 
organisms  in  an  excretion  or  secretion  without  an 
actual  invasion  of  the  tissues. ^ 

Several  simple  infections  may  coexist  at  one  time 
in  the  same  individual,  entirely  independent  of  and 
separated  distinctly  from  one  another.  Such  a  con- 
dition would  arise  if,  in  a  case  of  puerperal  endo- 
metritis due  to  pyogenic  streptococci,  there  existed  at 
the  same  time  a  gonorrhoeal  infection  of  the  urethra. 

The  expression  "  Primary  Mixed  Infection "  de- 
notes the  coincident  invasion  of  the  same  area  by 
two  or  more  varieties  of  parasitic  micro-organisms, 
whereas,  in  "  Secondary  Mixed  Infections  "  following 
the  settling  of  one  form  of  micro-organism  in  living 
tissue  and  during  its  continued  activity  there,  another 
organism  makes  effective  entrance  into  the  same 
region.     During  the  course  of  either  a  primary  or  a 

^  An  objection  to  this  contention  is  that  although  it  may  be  impossible  to 
demonstrate  the  presence  of  the  so-called  saprophytes  in  a  tissue  section^ 
their  activity  on  the  surface  of  the  mucous  membrane  or  in  ducts,  glands,  or 
lacuna?,  without  penetration  of  the  cells  or  intercellular  spaces,  may  give  rise 
to  an  inflammatory  reaction,  owing  to  the  irritation  produced  by  their  toxins 
or  otherwise.  Again,  organisms  which  at  one  step  of  an  inflammatory  process 
may  be,  as  defined  by  Menge,  purely  saprophytic  living  in  an  excretion  or 
secretion,  may  at  any  moment  of  a  later  stage  become  infective  owing  perhaps 
to  the  destruction  of  superficial  protecting  epithelium. 

It  has  also  to  be  noted  that  such  saprophytes  escaping  from  the  Fallopian 
tubes  into  the  peritoneum  might  be  responsible  for  a  peritonitis.  In  the 
same  way,  a  cystic  abscess  might  be  caused  by  the  inclusion  of  facultative 
saprophytes  in  the  cavity  of  a  gland,  when  the  duct  became  obstructed  by 
inflammatory  adhesion'. 


GONORRHCEA    IN   THE    FEMALE      259 

secondary  mixed  infection  the  disappearance  from 
the  scene  of  action  of  one  of  the  infecting  agents 
may  end  in  the  estabhshment  of  a  simple  infection, 
and  this  is  called  "  a  Simple  Secondary  Infection.^ ^ 

The  position  which  Menge  takes  up  in  relation  to 
the  finding  of  various  conflicting  organisms  in  a  smear 
preparation,  is  that  they  do  not  necessarily  indicate 
a  mixed  infection.  On  the  contrary,  a  true  mixed 
infection  in  gonorrhoea  rarely,  if  ever,  can  arise. 
To  obtain  a  smear  from  the  site  proper  to  the  growth 
of  the  gonococci  which  are  present  is  only  a  question 
of  technique,  and  if  a  specimen  can  be  got  directly 
from  the  gonococcal  area  uncontaminated  by  con- 
tact with  the  lower  passages  it  will  be  found  to  con- 
tain gonococci  in  pure  culture.  For  instance,  in 
gonococcal  endometritis  a  specimen  obtained  by 
approaching  the  endometrium  through  the  uterine 
wall  in  the  course  of  an  abdominal  operation  or  a 
post-mortem  examination  will  show  only  gonococci, 
an  entirely  different  picture  from  what  would  be  seen 
in  a  smear  taken  via  the  cervix  in  the  same  case. 

While  the  streptococcus,  staphylococcus,  and  the 
bacillus  coli  frequently  vegetate  as  saprophytes  in  the 
exudation  of  a  mucous  membrane  infected  with 
gonorrhoeal  inflammation,  the  gonococcus  never  does 
so.  It  thrives  only  in  and  upon  the  tissue,  and  any 
gonococci  found  in  the  exudation  have  been  separated 
from  the  mother  colonies  in  the  tissues  as  they  can- 
not survive  as  facultative  saprophytes  in  a  secretion. 
On  the  other  hand,  the  common  pyogenic  organisms 
and  the  bacillus  coli  may,  and  frequently  do,  exist  in 
secretions  and  inflammatory  exudations  merely  as 
facultative  saprophytes,  and  their  presence  there  in 
no  way  indicates  their  presence  in  the  tissues  furnish- 
ing the  exudation. 


260    GONORRHGEA  &  ITS  COMPLICATIONS 

The  gonococcus  is  an  extremely  delicate  organism 
and  very  sensitive  to  changes  in  its  environment. 
When  the  products  of  their  own  metabolism  or  the 
metabolism  of  other  germs  is  not  removed  by  drain- 
age, e.g.,  in  a  closed  tubo-ovarian  abscess,  gonococci 
soon  perish. 


CHAPTER  XV 

THE   TREATMENT   OF  GONOCOCCAL  INFECTION 
IN   WOMEN 

The  principles  which  govern  the  treatment  of  gono- 
coccal infection  in  the  male  apply  with  equal  force  to 
the  disease  in  the  female,  but  the  differing  anatomical 
and  physiological  conditions  necessitate  a  consider- 
able modification  of  the  methods  employed. 

Having  obtained  by  inspection  and  bacteriological 
examination  a  complete  knowledge  of  all  the  sites 
where  the  gonococcus  has  secured  lodgment,  these 
areas  which  are  within  reach  are  directly  attacked. 
The  antiseptics  chosen  should  have  at  the  same  time 
the  greatest  penetrating  and  the  least  irritating  action 
on  the  tissues  as  well  as  the  highest  specific  bacteri- 
cidal effect  on  the  gonococcus.  The  mode  of  applica- 
tion must  introduce  no  risk  of  any  further  extension 
of  the  infection,  and  reinoculation  must  be  guarded 
against  by  the  observance  of  the  strictest  cleanliness. 

General  treatment. — The  constituents  of  the  urine 
have  less  influence  on  the  disease  in  women,  either 
for  good  or  evil,  than  is  the  case  in  men.  Urethritis 
is  seldom  productive  of  much  discomfort,  painful 
urination  not  being  a  marked  feature  and  cystitis 
when  it  does  occur  usually  being  limited,  in  an  un- 
mixed gonococcal  infection,  to  a  collection  of  dis- 
crete patches  on  the  trigone.  The  balsams  and 
urinary  antiseptics  therefore  play  a  less  prominent 

261 


262    GONORRHCEA  &  ITS  COMPLICATIONS 

role  in  the  female  than  in  the  male.  When,  however, 
symptoms  of  dysuria  or  pyuria  arise,  sandalwood  oil 
in  capsules  and  hexamethylenamin  or  boric  acid  with 
atropine  or  hyoscyamus  and  uvse  ursi  are  indicated. 
In  all  acute  conditions  rest  in  bed  is  advisable  for  a 
few  days,  and  in  hyperacute  cases  with  excoriation 
and  oedema  it  is  essential.  The  same  regulations  as 
to  diet,  exercise,  and  general  hygiene  as  are  ap- 
plicable in  the  male  should  be  observed  by  female 
patients. 

Too  much  prominence  cannot  be  given  to  the 
necessity  for  maintaining  the  most  scrupulous  cleanli- 
ness. A  sanitary  towel  should  constantly  be  worn 
to  protect  the  clothing  from  contamination.  Sitz 
baths  containing  a  liberal  but  unirritating  proportion 
of  some  antiseptic  such  as  kerol  or  Jeyes'  fluid 
should  be  employed  several  times  daily  during  the 
acute  stage. 

Treatment  of  the  external  genital  surfaces. — On 
separating  the  labia  the  mucous  surfaces  should  be 
carefully  inspected  for  areas  of  reddening.  Para-ure- 
thral  passages  and  vulvar  crypts,  both  of  which  are 
exceedingly  common,  should  be  sought  for  and 
examined  bacteriologically  if  there  is  any  indication 
of  redness  or  purulent  exudation.  The  ducts  of  the 
Bartholin  glands  receive  similar  attention.  On  loca- 
ting the  gonococcus  in  any  of  these  localities,  syste- 
matic treatment  of  each  spot  must  be  begun  and 
persevered  with  until  the  gonococcus  is  exterminated. 
Protargol  (1-2  per  cent)  or  a  corresponding  concen- 
tration of  any  other  silver  preparation  is  applied  on 
fine  cotton- wrapped  probes  or  injected  through  a 
blunted  hypodermic  needle  as  may  be  found  neces- 
sary. This  should  be  repeated  daily,  varying  the 
strength  of  the  application  and  the  agent  employed 


PLATE  XI. 


Lactic  Acid  Bacillus. 


GONOCOCCAL  INFECTION  IN  WOMEN  263 

according  to  the  effect  produced.  Too  much  re- 
action from  over-treatment  must  be  avoided. 

Infected  para-urethral  passages,  crypts,  and  gland 
ducts  which  do  not  respond  to  this  treatment  may 
be  subjected  to  electrolysis  after  cocainizatioQ. 
Abscesses  arising  from  Bartholin's  glands  are  incised 
and  packed  with  gauze  damped  with  a  mild  silver 
solution. 

Treatment  of  the  urethra. — The  urethra  when  in- 
fected receives  injection  treatment  by  means  of  an 
all-glass  syringe  with  acorn  nozzle  and  a  capacity  of 
one  dram.  Protargol  (J-2  per  cent),  colossal  argen- 
tum,  iodargol,  etc.,  may  be  used  for  this  purpose. 
The  urethra  should  be  filled  several  times  at  each 
sitting  and  the  solution  retained  for  two  or  three 
minutes  each  time. 

Treatment  of  the  cervix. — After  thoroughly  swabbing 
the  vagina  with  biniodide  (1-2000),  lactic  acid 
(1-100),  or  other  antiseptic  with  the  aid  of  a  Sim's 
speculum  and  a  retractor,  the  cervix  is  displayed, 
the  external  os  carefully  cleaned,  and  the  cervical 
canal  treated  with  protargol  2  per  cent  or  whatever 
other  preparation  is  preferred.  This  is  best  carried 
out  by  means  of  long,  fine  wool-bearing  probes 
saturated  with  the  solution.  These  are  inserted  with 
a  gentle  rotatory  movement,  and  several  probes  are 
employed,  each  succeeding  probe  being  carried  a 
little  further  than  the  previous  one.  The  greatest 
care  must  be  exercised  not  to  dilate  the  internal 
OS  and  enter  the  uterus  unless  endometritis  is  indi- 
cated by  a  patent  internal  os  and  a  copious  flow  of 
muco-purulent  discharge.  Sometimes  it  is  necessary 
to  dilate  or  incise  the  external  os  to  allow  of  easy 
access  to  the  cervical  canal,  and  to  secure  satisfactory 
drainage,  especially  when,  as  occasionally  happens, 


264    GONORRHCEA  &  ITS  COMPLICATIONS 

the  canal  has  been  converted  into  a  sacculated 
cavity. 

Treatment  of  the  vagina. — Although  the  vaginal 
walls  of  the  adult  female  are  only  exceptionally  the 
seat  of  gonococcal  inflammation,  the  toxins  of  the 
cervical  discharge  irritate  the  vaginal  mucosa.  In 
the  resulting  sero-purulent  exudation  myriads  of 
saprophytic  organisms  thrive  and,  the  conditions 
being  unfavourable  to  its  growth,  the  bacillus  of 
Doderlein  retires  into  obscurity  or  entirely  disappears. 
Regular  cleansing  of  the  vagina  therefore  becomes  a 
necessity.  For  this  purpose  swabbing  is  more  effi- 
cient than  douching,  and  the  antiseptic  indicated  is 
the  B.P.  lactic  acid  in  a  concentration  of  1-100  to 
1-200.  When  douching  has  to  be  relied  on  the 
strength  should  be  1-300.  The  swabbing  should  be 
done  gently  but  thoroughly  each  day,  and  after  the 
vagina  has  been  carefully  dried  with  aseptic  wool  a 
liquid  culture  of  an  innocuous  lactic  acid  bacillus,  such 
as  the  bacillus  Bulgaricus,  recently  incorporated  with 
lactose  powder,  should  be  inserted  into  the  vagina  to 
take  the  place  of  the  defunct  Doderlein  bacillus. 
Some  strains  of  lactic  acid  bacilli  will  not  survive 
many  days  in  the  dry  state,  and  it  is  therefore  ad- 
visable to  make  the  preparation  freshly  or  at  least 
once  a  week. 

Summary  of  the  local  treatment  in  the  female. — The 
treatment  of  gonorrhoea  in  women  may  be  summarised 
by  describing  shortly  the  method  which  has  been 
evolved  at  the  Glasgow  Lock  Hospital. 

After  a  prolonged  sitz  bath,  containing  about  an 
ounce  of  kerol,  the  vagina  is  carefully  and  gently 
swabbed  with  1-2000  biniodide  of  mercury  solution, 
or  1-100  lactic  acid.  Various  other  antiseptics  may 
be  used,  e.g.,  perchloride  or  oxycyanide  of  mercury, 


GONOCOCCAL  INFECTION  IN  WOMEN  265 

iodine,  formalin,  etc.  Care  must  be  taken  to  remove 
all  trace  of  the  mercurial  antiseptic,  and  the  next 
procedure  is,  therefore,  to  swab  well  with  plain  sterile 
water,  and  then  dry  with  wool.  Colossal  argentum  or 
protargol,  1-2  per  cent,  is  then  thoroughly  applied  to 
each  infected  area,  the  urethra,  cervix,  and  every 
reddened  patch  or  pocket  receiving  careful  treatment 
with  wool-wrapped  probes  dipped  in  the  solution,  or 
by  means  of  injections  through  blunted  hypodermic 
needles  where  probes  cannot  enter.  The  parts  are 
again  dried,  the  cervix  when  patent  lightly  packed 
with  lactic  bacillus  powder,  a  bacillus  pessary  in- 
serted high  up  in  the  vagina,  and  the  patient  returned 
to  bed. 

This  routine  is  carried  out  night  and  morning  for 
three  or  four  days,  when  the  condition  will  be  found 
to  have  greatly  improved  as  regards  the  quantity  of 
discharge  and  the  presence  of  saprophytic  organisms. 
We  then  rely  on  lactic  acid  1-100  to  1-200  as  the 
only  antiseptic  for  swabbing,  and  the  powder  and 
pessaries  as  before.  The  silver  preparation  is  con- 
tinued for  the  urethra  and  all  vulvar  recesses  harbour- 
ing gonococci,  but  the  cervix  and  vagina,  as  a  rule, 
only  receive  lactic  acid  swabbing  and  the  powder  and 
pessary,  whose  composition  I  must  now  explain.  I 
started  in  1909  to  use  lactic  acid  bacilli  for  the 
treatment  of  gonorrhoea  in  women.  Several  methods 
of  applying  this  agent  have  since  been  tried,  and 
the  outcome  of  our  experiments  is  a  mixture  of  a 
liquid  culture  of  lactic  acid  bacilli  and  sugar  of  milk, 
allowed  to  dry  under  aseptic  conditions.  While  the 
mixture  is  damp  and  mouldable,  short  rods  are 
punched  out  of  the  doughy  mass,  and  after  drying 
are  used  as  pessaries.  The  remnants  are  allowed  to 
dry,  and  are  then  crushed  into  powder  form.     The 


266    GONORRHCEA  &  ITS  COMPLICATIONS 

preparation  has  to  be  made  weekly,  as  the  bacilH 
lose  their  activity  if  kept  long  in  the  dry  state. 

There  are  doubtless  plenty  of  innocuous  lactic  acid 
producing  organisms  which  could  equally  well  serve 
our  purpose,  and  whose  vitality  would  not  suffer  from 
being  made  into  tablet  form,  but  we  get  such  good 
results  from  our  present  method  that  I  am  loath 
to  change  since  we  have  in  the  laboratory  facilities 
for  making  the  product. 

But  for  use  in  general  practice  it  is  highly  desir- 
able that  a  preparation  which  will  keep  active  for 
a  reasonable  period  should  be  put  on  the  market, 
and  I  hope  that  this  will  soon  be  accomplished. 
Meantime  the  admixture  of  one  of  the  fluid  cul- 
tures with  sugar  of  milk,  under  strict  aseptic  pre- 
cautions, will  furnish  a  paste  which  will  serve  the 
purpose  excellently. 

The  rationale  of  this  treatment  I  can  only  tenta- 
tively explain,  but  the  clinical  effects  are  highly 
satisfactory,  and  I  know  of  no  other  method  of 
arriving  at  anything  like  the  same  results.  To 
attempt  to  eradicate  the  gonococcus  from  the  cervix 
and  uterus  by  applications  of  gonococcal  antiseptics, 
however  energetic,  is  wellnigh  hopeless.  Our  use  of 
a  preliminary  antiseptic  treatment  shows  what  benefit 
can  be  got  in  this  way  ;  but  when  a  certain  stage  has 
been  reached  no  further  progress  seems  to  be  attain- 
able, and  only  by  continuing  indefinitely  the  anti- 
septic measures  can  this  improvement  be  maintained. 
The  point  where  one  can  say  that  absolute  cure  has 
been  effected,  the  gonococcus  being  permanently 
absent  from  the  smears,  has  been  very  difficult  to 
realise  in  women.  The  addition,  however,  of  the 
lactic  acid  bacillus  to  our  therapy  alters  the  whole 
picture. 


GONOCOCCAL  INFECTION   IN  WOMEN  267 

Now,  by  what  hypothesis  can  our  results  be  ex- 
plained ?  We  use  two  agents  not  generally  used  by 
others.  One,  sugar  of  milk,  is  known  to  have  an 
inhibiting  action  on  microbic  growth,  and  doubtless 
some  proportion  of  the  credit  must  be  awarded  to 
the  saccharine  material.  But  sugar  alone,  while 
helpful,  fails  in  practice  to  give  the  full  benefit  de- 
rived from  the  combination.  The  other,  the  lactic 
acid  bacillus,  is  the  more  active  partner,  but  it  re- 
quires the  sugar  as  a  medium  for  growth  and  for  the 
production  of  one  at  least  of  the  agencies  by  which 
it  effects  its  beneficial  powers,  viz.,  the  lactic  acid. 
The  gonococci  embedded  in  the  epithelial  and  sub- 
epithelial tissues  are  beyond  the  reach  of  its  action, 
but  the  growth  of  superficial  colonies  from  which  the 
deeply  lying  organisms  are  recruited  is  prevented. 
The  continuous  antiseptic  action  of  the  nascent  lactic 
acid  destroys  the  surface  organisms  in  glands  and 
crevices  more  effectively  than  any  temporary  appli- 
cation of  an  ordinary  antiseptic  can  be  expected  to 
accomplish.  But  we  may  accept  that  there  is  in 
addition  a  healing  effect  on  the  protective  epithelium, 
in  part  directly  due  to  the  astringent  action  of  the 
acid,  and  in  greater  part  due  to  the  absence  of  the 
destructive  toxins  of  the  pygemic  organisms. 

There  is  certainly  a  great  reduction  in  the  quantity 
of  secretion  poured  out  by  the  mucous  surfaces,  and  it 
may  reasonably  be  inferred  that  the  toxins  of  the 
deeply  situated  gonococci  which  usually  escape  in  this 
secretion  are  diverted  into  the  normal  channels  of 
absorption,  and  thus  reach  the  general  circulation, 
where  they  may  be  counted  on  to  stimulate  the 
formation  of  antibodies  in  quantity  sufficient  to  cope 
with  the  gonococci  embedded  in  the  tissues,  and, 
therefore,  within  reach  of  their  action.     In  this  way 


268    GONORRHOEA  &  ITS  COMPLICATIONS 

a  natural  vaccine  therapy  is  excited  and  the  gonococ- 
cus  ultimately  exterminated. 

Several  modes  of  treating  vaginal  discharge  have 
been  tried,  but  in  my  experience  none  can  compare 
in  effectiveness  with  that  outlined  above.  Packing 
the  vagina  with  gauze  impregnated  with  various 
medicaments,  dusting  or  filling  it  with  absorbent 
powders,  distending  it  with  dilute  chlorine  gas  and 
repeated  and  prolonged  douching  have  now^  been 
discarded  in  my  practice  in  favour  of  the  lactic  acid 
treatment. 

The  treatment  of  chronic  injections  in  the  female. — 
There  is  little  to  add  to  what  has  already  been  said. 
In  cases  which  fail  to  respond  within  three  or  four 
weeks  to  the  above  treatment,  careful  examination 
will  show  the  presence  of  a  subacute  or  chronic  tubal 
abscess  draining  into  the  uterus  or  an  infected  tubule 
or  crypt,  which  has  escaped  observation.  When  the 
urethra  is  the  seat  of  a  chronic  infection,  Skene's 
ducts  should  be  inspected,  and,  if  necessary,  treated 
through  the  urethroscope,  and  the  bladder  may 
be  examined  cystoscopically.  The  Bier  method  may 
be  applied  to  the  cervix  in  subacute  and  chronic 
cases  by  means  of  the  special  glass  tube  made  for  the 
purpose.  It  certainly  assists  in  emptying  the  numer- 
ous cervical  glands  of  their  contents,  and  it  may 
ultimately  prove  of  service  in  combination  with  vaccine 
or  serum.  Before  adjusting  the  tube,  the  cervix 
should  be  well  cleansed  and  a  generous  supply  of  the 
silver  solution  left  in  the  canal.  The  silver  solution 
should  be  reapplied  after  removal  of  the  extracted 
secretion.  This  method,  a  hospital  matron  tells  me, 
is  not  suitable  for  indiscriminate  use. 

It  seems  hardly  necessary  to  state  that,  through- 
out the  existence  of  a  gonococcal  infection  of  whatever 


GONOCOCCAL  INFECTION  IN  WOMEN  269 

nature,  coitus  must  be  refrained  from.  Not  only  is 
there  the  risk  of  infection  being  conveyed  to  another, 
but  also  of  an  exacerbation  being  excited  in  the 
patient.  There  is  nothing  so  likely  to  produce  sal- 
pingitis and  other  complications  as  coitus.  In  my 
experience  salpingitis  is  much  more  frequent  in 
married  women  and  in  habitual  prostitutes  than  in 
cases  where  connection  is  not  repeated  after  infection. 
Another  relative  point  in  the  case  of  married  women 
is  to  ascertain  before  sanctioning  cohabitation  that 
the  husband  is  not  a  carrier  of  disease. 


ASSURANCE    OF    CURE    IN    FEMALE    PATIENTS 

How  can  we  convince  ourselves  that  a  patient  is 
cured  and  free  from  risk  of  recurrence  ?  In  the  first 
place  there  is  the  absence  of  all  abnormal  appearances 
of  the  genital  tract  :  no  purulent  discharge  or  areas 
of  redness  are  seen  on  separating  the  labia  or  on  dis- 
playing the  cervix ;  also  no  gonococci  can  be  found 
on  prolonged  and  repeated  search  either  in  urethral 
or  cervical  smears. 

In  case  of  doubt  it  is  possible  to  excite  any  latent 
gonococci  into  renewed  activity,  so  that  they  can  be 
found  in  smears,  by  shghtly  irritating  applications, 
such  as  1-1000  nitrate  of  silver  solution,  or  by  a 
hypodermic  injection  of  a  small  dose  (five  to  ten 
milhon)  of  vaccine.  If  they  are  present  they  should 
be  found  and  destroyed.  It  is  not  wise  in  this  case  to 
"  let  sleeping  dogs  lie."  The  intradermic  vaccine  re- 
action and  the  complement-fixation  test,  if  distinctly 
negative,  are  of  diagnostic  value,  but  it  is  not  yet 
definitely  ascertained  how  long  positive  reactions 
may  survive  in  the  absence  of  the  gonococcus.  These 
reactions  merely  indicate  the  presence  of  antibodies 


270    GONORRHCEA  &  ITS  COMPLICATIONS 

in  the  blood,  and  it  is  probable  that  these  antibodies 
continue  to  exist  for  short  periods,  varying  in  different 
individuals,  after  the  final  extinction  of  the  organisms. 
The  skin  test  is  easily  applied.  These  tests  are  de- 
scribed in  the  chapter  on  immunity  reactions. 


CHAPTER    XVI 

COMPLICATIONS   OF   GONOCOCCAL   INFECTION 
IN   THE   FEMALE 

All  the  various  conditions  by  which  entrance  of  the 
gonococcus  into  the  blood-stream  can  evidence  itself 
may  occur  at  any  time  throughout  the  existence  of 
the  disease.  So  long  as  a  local  focus  of  gonococcal 
infection  persists,  there  is  the  risk  of  rheumatic 
affections  of  the  j-oints  and  tendon  sheaths,  endocar- 
ditis and  pericarditis,  phlebitis,  pleurisy,  iritis,  con- 
junctivitis, or  even  grave  septicaemia. 

The  most  important  element  in  the  cure  of  these 
conditions  is  cutting  off  the  supply  of  the  invading 
organisms  by  destroying  the  foci  of  infection  in  the 
genital  tract.  Vaccine  therapy  is  also  of  value,  but 
there  are  several  points  regarding  the  action  of 
gonococcus  vaccine  which  require  elucidation  before 
it  can  take  an  assured  place  in  treatment. 

Bartholin  abscess,  or  rather,  pseudo-abscess,  it 
being  really  a  suppurating  retention  cyst,  is  of 
frequent  occurrence.  A  small  incision  to  allow  of 
drainage  is  sufficient,  and  the  cavity  is  regularly  in- 
jected with  silver  solution  and  packed  with  gauze 
until  germ-free. 

Para-urethral  passages  and  vulvar  pockets,  so  fre- 
quently present  in  women,  must  be  carefully  looked 
for  and  treated  with  silver  solution  if  found  infected, 
otherwise  they  will  prove  a  source  of  reinfection. 

271 


272    GONORRHOEA  &  ITS  COMPLICATIONS 

When  the  urethra,  in  spite  of  treatment,  still  gives 
a  positive  smear,  it  is  necessary  to  use  the  urethro- 
scope or  a  speculum  (Fig.  65)  to  locate  and  treat  any 
duct  or  crevice  which  may  not  be  receiving  sufficient  of 
the  ordinary  application.  Skene's  ducts,  which  open 
into  the  urethra,  may  be  the  cause  of  a  continued 
infection. 

Gonococcal  cystitis  is  suggested  by  the  presence  of 
a  quantity  of  pus  in  the  urine.  A  small  amount  of 
pus  may  originate  in  the  urethra,  or  vulvar  or  vaginal 
pus  may  accidentally  be  mixed  with  the  urine.  To 
ascertain   the    condition    of   the    bladder    accurately 


Fig.  65. 
Parnell's  speculum  for  the  female  urethra. 

it  is  necessary  for  the  nurse  to  cleanse  the  whole 
vagina  and  request  the  patient  to  pass  urine  in  two 
portions.  The  first  specimen  contains,  in  addition 
to  the  contents  of  the  bladder,  all  pus  washed  out 
from  the  urethra,  while  the  second  shows  the  con- 
dition of  the  bladder. 

It  is  not  wise  to  cystoscope  a  bladder  in  acute 
conditions,  but  all  that  would  be  seen  in  gonococcal 
cystitis  is  a  varying  number  of  small  reddened  areas 
with  injected  margins  scattered  over  the  trigone. 
The  treatment  consists  in  washing  out  the  bladder 
with   a  weak  solution  of  permanganate    of    potash 


INFECTION   IN   THE   FEMALE         273 

1-8000  to  1-4000,  or  one  of  the  organic  silver 
preparations,  e.g.,  albargin  1-5000  to  1—2000.  A 
urinary  antiseptic  is  also  advisable,  and  in  pre- 
scribing such  it  is  necessary  to  know  the  reaction  of 
the  urine.  If  it  is  frankly  acid  or  can  be  rendered 
acid  by  administering  the  acid  phosphate  of  soda  in 
30-grain  doses  three  times  daily,  urotropine  is  indi- 
cated, otherAvise  boric  acid  is  to  be  preferred.  Uvse 
ursi,  which  is  antiseptic  and  diuretic,  is  a  suitable 
vehicle.  Sandalwood  oil  is  also  of  service  both  as 
an  antiseptic  and  sedative.  It  is  prescribed  in  10- 
minim  capsules  three  or  four  times  a  day  after  meals. 

Extension  to  the  kidneys  is  a  grave,  but  fortunately 
uncommon,  complication.  The  treatment  is  ureteral 
silver  injections  (see  p.  306). 

Condylomata  acuminata  (venereal  warts)  are  fully 
described  in  a  later  chapter. 


GONOCOCCAL   INFECTION   OF   THE   UTERINE 
MUCOSA 

It  is  usually  taught  that  gonococcal  infection  is  in 
the  great  majority  of  cases  limited  to  the  cervix, 
and  that  only  occasionally  does  the  inflammatory 
process  extend  beyond  the  internal  os,  and  that 
when  extension  upward  does  occur  the  tubes  are 
usually  implicated.  The  general  impression  has  been 
that  the  uterine  mucosa  did  not  form  a  very  suitable 
nidus  for  the  propagation  of  the  gonococcus,  but 
that  it  was  capable  of  passing  on  the  infection  to  the 
Fallopian  tubes,  when  a  typical  salpingitis  would 
develop  with  perhaps  an  accompanying  pelvic  peri- 
tonitis. Bumm  has  had  most  influence  in  spreading 
this  belief,  but  his  teaching  is  insufficiently  supported 
either  by  clinical  observations  or  by  bacteriological 

WATSON — T 


274    GOXORRHCEA  &  ITS  COMPLICATIONS 

investigations.      He    asserted    that    gonorrhoea!    en- 
dometritis was  ushered  in  by  severe  feverish  symp- 
toms, and  that  it  was  of  rare  occurrence.     There  is, 
however,  no  reason  to  be  found  in  the  histological 
structure  of  the  endometrium  why  gonococci  should 
not    flourish    thereon,    and    no    permanently    closed 
sphincter  to  separate  the  cervix  from  the  cavity  of 
the  uterus.     Moreover,  Wertheim  has  demonstrated 
gonococci  in  curetted  portions  of  the  endometrium 
from  both  acute  and  chronic  cases.     He  states  that 
no  special  symptoms  accompanied  the  involvement 
of  the  uterine  mucosa  in  the  acute  cases  by  which  an 
endometritis  as  distinct  from  an  endocervicitis  could 
be  diagnosed.     However,  Bumm's  assertion  that  an 
increase   in   temperature   accompanies   acute   gonor- 
rhoeal  endometritis  is  true  in  some  cases.     It  is  fre- 
quently   impossible    to    decide    by    any    justifiable 
method  of  diagnosis  whether  the  uterine  cavity  has 
been  involved,  but  I  am  convinced  that  it  is  much 
more  frequent  than  has  been  generally  believed.     If 
the  internal  os  is  open,  the  uterus  palpably  enlarged, 
and  the  quantity  of  exuding  muco-purulent  secretion 
considerable,   it  may  be  accepted  that  the  uterine 
mucosa  is  actively  attacked. 

As  factors  favourable  to  the  spread  of  the  infection 
to  the  endometrium  may  be  mentioned  menstruation, 
the  puerperium,  coitus,  and  instrumental  interfer- 
ence. The  same  influences  may  determine  an  attack 
of  salpingitis  from  the  passage  of  the  gonococcus  into 
the  Fallopian  tubes  ;  but  as  it  is  true  that  the  in- 
ternal OS  acts  as  a  barrier  in  some  cases  to  the  exten- 
sion of  the  gonorrhoeal  infection,  so  also  should  the 
more  minute  uterine  orifices  of  the  Fallopian  tubes 
in  a  still  greater  proportion  check  the  further  spread 
of  the  disease. 


INFECTION    IN   THE   FEMALE         275 


GONOCOCCAL   ENDOMETRITIS 

About  half  of  all  cases  of  endometritis  are  gonococ- 
cal in  origin.  Gonococcal  endometritis  may  be  acute 
or  subacute,  and  both  of  these  forms  may  merge  into 
a  chronic  endometritis.  The  onset  of  endometritis  is 
usually  insidious,  and  the  subacute  type  prevails,  but 
occasionally  a  more  acute  invasion  is  met  with. 

Symptoms  of  acute  endometritis. — The  temperature 
is  raised,  but  seldom  exceeds  101-5°  F.  ;  the  pulse 
ranges  from  100  to  120  and  the  general  symptoms  of 
fever  are  present.  Pain  is  complained  of  in  the 
suprapubic  region,  and  there  may  be  slight  symp- 
toms of  bladder  and  rectal  irritation. 

Bimanual  examination,  which  must  be  conducted 
with  gentleness,  will  discover  the  uterus  slightly  en- 
larged, and  pain  will  be  elicited  by  manipulation. 
There  is  always  some  degree  of  metritis  present.  On 
inspection  of  the  cervix  a  day  or  two  after  the  onset 
a  profuse  glairy  discharge  (muco-purulent  at  a  later 
stage)  will  be  seen  exuding  from  the  patulous  os  of 
an  enlarged  reddened  cervix,  unless  the  internal  os  is 
closed,  in  which  case  the  excessive  discharge  will 
appear  intermittently. 

The  gonococcal  nature  of  the  infection  is  proved 
by  finding  the  organism  in  smears  and  cultures  from 
the  cervical  discharge.  It  is  not  practicable  to 
obtain  an  intrauterine  swab  on  account  of  the  risk 
of  causing  spread  of  the  infection  to  the  tubes. 

Treatment. — Rest  in  bed,  regulation  of  the  boAvels, 
suitable  diet,  hot  suprapubic  applications,  hot  sitz 
baths,  large  hot  vaginal  douches  of  1-300  to  1-500 
lactic  acid,  followed  by  the  insertion  of  the  lactic  acid 
bacillus   pessaries,    will   result   in   subsidence   of   the 


276    GONORRH(EA  &  ITS  COMPLICATIONS 

symptoms  within  a  few  days  unless  the  tubes  are 
involved.  I  believe  that  quinine  is  of  some  value  in 
these  cases.  Atropine  should  be  used  as  a  sedative 
and  to  obviate  peristalsis  of  infective  material  into 
the  tubes. 

Subacute  endometritis  is  much  more  common,  but  is 
more  difficult  to  diagnose  unless  as  an  accompani- 
ment of  salpingitis.  It  can  be  inferred  Avhen  the 
cervical  discharge  is  excessive,  when  the  uterus  is 
enlarged  and  the  internal  os  readily  entered  while 
probing  the  cervix.  The  patency  of  the  internal  os  is 
perhaps  the  most  suggestive  symptom.  This  will 
not  be  discovered  while  irritating  solutions,  which 
stimulate  contraction,  are  being  used  to  the  cervix. 

It  requires  no  special  treatment  other  than  that 
already  outlined.  Local  applications  to  the  endo- 
metrium should  be  withheld. 

Chronic  gonococcal  endometritis  is  of  significance 
principally  on  account  of  the  constant  danger  of  the 
onset  of  salpingitis  and  also  as  a  cause  of  sterility 
and  of  continued  infectivity. 

The  symptoms  are  the  same  as  in  subacute  endo- 
metritis, with  the  addition  that  the  menstrual  func- 
tions may  be  interfered  with.  Thus  there  may  be 
irregularity,  menorrhagia,  or  dysmenorrhoea.  The 
dysmenorrhoea  is  of  the  congestive  type,  the  pain 
persisting  during  the  first  two  or  three  days  of  the 
flow. 

Treatment. — Before  undertaking  any  local  treat- 
ment it  is  necessary  to  ascertain  with  as  great  ac- 
curacy as  is  possible  that  neither  of  the  tubes  have 
been  infected.  If  a  quiescent  salpingitis  exists  an 
exacerbation  may  be  determined  by  any  intrauterine 
instrumentation.  The  usual  treatment  recommended 
is  dilatation  and  curettage  followed  by  the  applica- 


INFECTION   IN   THE   FEMALE         277 

tion  of  tincture  of  iodine  or  other  strong  antiseptic 
solution. 

But  it  is  impossible  to  remove  or  destroy  the 
entire  endometrium  and  its  infected  glands  ;  and  if 
this  could  be  done  obliteration  of  the  uterine  cavity 
would  result.  It  is  therefore  entirely  a  matter  of 
chance  and  seldom  realised  that  the  infection  is 
completely  exterminated.  The  result  frequently  is  that 
no  benefit  is  derived,  and,  in  the  event  of  no  harm 
ensuing,  the  patient  has  at  least  run  an  unnecessary 
risk.  I  do  not  dispute  that  in  a  carefully  selected 
case,  curetting  may  be  advantageous  and  hasten 
recovery,  but  I  am  strongly  of  opinion  that  in  the 
majority  of  cases  in  which  it  is  undertaken  it  is  use- 
less, and  in  not  a  few  harmful. 

When  curetting  is  decided  upon,  it  should  be  per- 
formed immediately  following  menstruation  when  the 
mucosa  will  be  thin,  and  it  should  be  followed  by 
careful  drying  of  the  uterus  and  a  thorough  swabbing 
with  tincture  of  iodine. 

Short  of  curetting,  the  local  treatment  of  the 
endometrium  usually  adopted  consists  of  injections 
or  swab  applications  of  tincture  of  iodine,  formalin, 
strong  silver  nitrate  (1  dram  to  the  ounce),  carbolic 
acid,  etc.  These  are  all  equally  disappointing.  Since 
having  given  up  curetting  and  caustic  applications, 
my  results  have  been  much  more  satisfactory,  and 
cure  has  been  more  quickly  attained. 

It  is,  in  fact,  a  hopeless  task  to  attempt  to  abort 
gonorrhoea  in  the  female.  Cases  at  a  stage  of  infection 
sufficiently  early  to  make  this  procedure  feasible 
rarely  come  under  observation,  and  although  the 
cervical  and  uterine  tissues  may  be  subjected  to  a 
much  more  energetic  treatment  than  is  possible  in 
the  male  urethra,  no  line  of  radical  treatment  short 


278    GONORRHCEA  &  ITS  COMPLICATIONS 

of  hysterectomy  promises  much  hope  of  success. 
The  gonococcus  quickly  penetrates  the  glands  and 
the  tissues  to  a  depth  beyond  reach  of  the  curette 
and  antiseptic,  and  it  lies  dormant  in  these  safe  re- 
treats until  the  mucosa  is  reconverted  into  a  medium 
suitable  for  its  growth,  when  it  springs  into  renewed 
activity. 

It  is  of  the  utmost  importance  in  treating  the 
endometrium  to  adopt  some  precaution  which  will 
obviate  the  risk  of  forcing  infected  material  into  the 


Fig.  66. 
Watson's  uterine  speculum. 

tubes.  With  this  object  in  view,  I  employ  a 
uterine  speculum  (Fig.  66),  through  which  the  solu- 
tion can  be  injected  or  applied,  and,  instead  of  the 
ordinary  probes,  use  metal  tubes  with  rounded  and 
open  ends  and  suitable  curve,  to  which  the  wool  is 
attached  (Fig.  67).  Another  method  is  to  insert  a 
double-channel  canula,  through  one  division  of  which 
the  solution  may  be  injected.  In  none  of  these  pro- 
cedures is  the  intrauterine  pressure  increased,  as  may 
so  readily  happen  in  the  passage  of  the  ordinary  wool- 
wrapped  probe.  With  the  os  closed  as  it  is  by  the 
Playfair  probe,  any  rise  in  the  intrauterine  pressure 
tends  to  adjust  itself  by  the  escape  of  the  uterine 
contents  into  the  Fallopian  tubes. 

Treatment  of  the  cervix  or  endometrium  by  caustic 


INFECTION   IN   THE   FEMALE         279 

applications  in  most  cases  delays  cure,  and  is  seldom 
of  any  benefit.  If  there  are  any  definite  lesions  which 
should  obviously  be  destroyed,  such  as  Nabothian 
cysts,  granulations,  papillomata,  or  polypi,  they 
should  be  treated  by  incision,  curetting,  or  electro- 
lysis, preceded  and  followed  by  unirritating  antiseptic 
solutions.  The  indiscriminate  use  of  strong  caustic 
solutions  is  one  of  the  mistakes  of  gynaecological 
practice,  and  the  same  remark  applies  to  many,  if 
not  most,  of  the  curettage  operations  which  are  under- 
taken. 

The  only  intrauterine  treatment  I  noAV  employ  is 
applied  through  the  uterine  speculum  or  by  means  of 


Fig.  67. 
Uterine  applicator. 

the  tubular  sound,  and  unirritating  solutions  are  used, 
such  as  iodargol,  colossal  argentum,  or  5  per  cent 
protargol  or  the  powdered  lactic  acid  bacillus  pre- 
paration. But  it  is  seldom  that  treatment  carried 
out  on  the  lines  indicated  for  cervical  gonorrhoea  is 
not  found  sufficient.  Unless  the  tubes  are  involved, 
perseverance  will  be  rewarded  by  the  disappearance 
of  gonococci  in  from  three  to  six  weeks  even  Avhen 
endometritis  is  present. 

GONOCOCCAL   INFECTION   OF  THE    FALLOPIAN    TUBES, 
OVARIES,    AND    PERITONEUM 

For  a  full  discussion  on  pelvic  inflammatory  con- 
ditions recourse  must  be  had  to  books  on  gynae- 
cology,  but   there   are   some   points    of   view   which 


280    GONORRHCEA  &  ITS  COMPLICATIONS 

perhaps   are   not   sufficiently   appreciated  by  gynse- 
cologists  and  which  may  be  presented  here. 

Extension  to  the  Fallopian  tube  is  most  prone  to 
occur  following  menstruation,  sexual  connection, 
abortion,  or  parturition.  The  gonococcus  may  reach 
the  tube  by  means  of  mucous  currents,  peristaltic 
action,  instrumentation,  or  by  direct  extension  from 
an  endometritis.  It  immediately  produces  its  charac- 
teristic inflammation  with  purulent  exudation.  The 
pus  may  escape  from  either  end  of  the  tube.  In  the 
uterus  the  discharge  excites  an  endometritis  if  this 
is  not  already  existent.  In  the  pelvis  a  plastic  peri- 
tonitis is  produced  with  rapid  formation  of  adhesions 
closing  the  internal  ostium  and  preventing  further 
leakage  in  this  direction.  The  uterine  end  of  the  tube 
soon  also  becomes  occluded  and  the  tube  converted 
into  a  pus  sac.  When  this  has  been  achieved  the 
symptoms  usually  decline  in  severity,  the  contents  of 
the  tube  ultimately  become  sterile  (two  to  three 
months),  and  gradual  absorption  takes  place  with 
continued  improvement  in  the  patient's  health.  This 
cycle  of  events  being  the  rule  in  gonococcal  salpin- 
gitis, palliative  treatment  in  contradistinction  to 
operative  treatment  is  obviously  indicated. 

Symptoms. — The  symptom  which  usually  first  at- 
tracts attention  to  the  onset  of  salpingitis  is  pain. 
It  is  most  marked  in  the  corresponding  inguinal 
region  and  tenderness  is  also  obtainable  in  the  same 
area.  The  pain  may  radiate  across  the  abdomen  and 
back,  and  down  the  thigh.  There  is  usually  constipa- 
tion, on  account  of  the  pain  attending  the  act  of 
defecation.  The  temperature  rises  to  round  103°  F., 
the  pulse  attains  120,  and  the  general  signs  of  fever  are 
present.  The  menstrual  functions  are  usually  disturbed. 

A  bimanual  examination  is  necessary  to  settle  the 


Fig. 


Acute  Gonorrhceal  Salpingitis. 

This  specimen  was  removed  during  the  early  stage  of  the  disease.  The  tube  is  somewhat  uniformly 
enlarged,  much  bent  upon  itself,  and  presents  numerous  adhesions.  The  abdominal  ostium  is  patulous. 
The  fimbrise  are  greatly  swollen  and  everted.  On  milking  the  tube,  pus  could  be  expressed  through 
both  ends.— [Norris.] 


■..i-L.5lijiSjJfct. -. 


Fig.  69. 


GONORRHCEAL    SALPINGITIS. 


The  section  has  been  taken  through  the  ampulla  of  the  tube.  The  muscularis  is  thin,  and  contains 
numerous  areas  of  inflammatory  infiltration.  The  mucous  folds  are  gracile,  and  their  epithelium  is 
somewhat  flattened  and  degenerated.  Bat  few  pseudo-glands  are  present.  On  macroscopic  examin- 
ation a  little  pus  could  be  seen  ia  the  tube.  The  abdominal  ostium  was  open,  although  somewhat 
contracted  ( x  16).     [Norris] . 


INFECTION   IN    THE    FEMALE         281 

diagnosis,  but  it  must  be  conducted  with  the  greatest 
gentleness.  Careless  handling  is  very  likely  to 
separate  restricting  adhesions,  and  to  cause  leakage 
of  pus  into  the  peritoneal  cavity. 

One  tube  only  is  affected,  in  the  first  instance  at 
least.  The  other  may  become  involved  later.  There 
will  probably  be  some  increased  resistance  felt  in  the 
pouch  of  Douglas,  and  fear  will  compel  the  patient 
to  contract  the  abdominal  muscles.  But  an  expert 
examiner  will,  without  the  exercise  of  any  force, 
in  almost  any  case  be  able  to  outline  the  affected 
tube.  According  to  the  stage  and  the  acuteness  of 
the  disease,  the  inflamed  mass  will  vary  from  the  size 
of  a  finger  to  that  of  an  orange.  It  may  sink  into  the 
pouch  of  Douglas  behind  the  uterus  or  it  may  be 
fixed  by  adhesions  higher  in  the  pelvis  ;  the  latter 
position  is  more  frequent.  The  ovary  is  usually  more 
or  less  involved  in  the  inflammatory  process,  and 
there  are  also  localised  areas  of  pelvic  peritonitis  with 
resulting  adhesions. 

Treatment. — The  essential  element  in  the  treatment 
is  to  ensure  rest  of  the  parts  to  allow  of  rapid  limita- 
tion of  the  area  involved  by  the  growth  of  adhesions. 
Rest  in  bed  in  the  upright  (Fowler)  position,  if  it  can 
be  maintained  with  comfort,  tends  to  promote 
uterine  drainage  and  to  assist  in  localising  the  in- 
flammation in  the  pelvis.  Hot  applications  to  the 
abdomen  are  soothing,  and  in  the  later  stages  pro- 
mote absorption.  No  treatment  involving  intrapelvic 
manipulation  is  justifiable  in  the  most  acute  stage. 
Later,  copious  hot  douches  of  weak  lactic  acid  and 
in  addition  tampons  saturated  with  10  per  cent 
ichthyol  and  2  per  cent  lactic  acid  inserted  on  two 
days  each  week,  and  the  lactic  acid  bacillus  pessaries 
on  the  other  days,  are  beneficial. 


282    GONORRHCEA  &  ITS   COMPLICATIONS 

The  use  of  electrically  heated  vaginal  tubes  has 
been  warmly  advocated  as  tending  to  promote 
absorption  and  also  inhibition  of  gonococcal  growth. 

Surgical  interference  is  rarely  justified  in  purely 
gonococcal  disease  in  the  pelvis.  The  role  of  surgery 
is  limited  to  the  late  separation  of  adhesions,  and 
plastic  operations  to  restore  the  parts  to  a  condition 
in  which  they  may  be  enabled  to  perform  their 
physiological  functions.  The  intrusion  of  a  virulent 
streptococcus  or  other  pyogenic  organism  into  a 
field  weakened  by  the  previous  activity  of  the  gono- 
coccus  may,  of  course,  necessitate  active  surgical 
intervention. 


GONOCOCCAL  INFECTION   AND    PREGNANCY 

Gonococcal  infection,  while  it  decreases  the  prob- 
ability of  conception,  does  not  negative  the  possi- 
bility. Whether  a  woman  is  rendered  sterile  or  not 
depends  on  the  areas  involved  and  the  amount  of 
damage  inflicted.  Gonococcal  infection  may  be 
coincident  with  conception,  it  may  follow  it,  or  pre- 
cede it.  Therefore  all  stages  of  gonorrhoea — acute, 
subacute,  or  chronic — are  met  with  in  pregnant 
women  ;  but,  as  the  pregnant  state  seems  to  furnish 
the  gonococcus  with  the  conditions  which  favour  its 
growth,  the  symptoms  are  more  marked,  exacerba- 
tions more  frequent,  and  complications  more  liable 
to  supervene.  It  is  calculated  that  from  5  to  10 
per  cent  of  pregnant  women  harbour  the  gono- 
coccus, and  that  from  15  to  30  per  cent  of  cases 
of  puerperal  fever  are  directly  or  indirectly  due  to 
the  organism. 

It  need  hardly  be  said  that  pregnancy  increases  the 
urgency   of  the   case.     Looking   at   the   cervix   of   a 


INFECTION    IN    THE  FEMALE         283 

pregnant  uterus  bathed  in  offensive  pus  we  see  how 
auto-infection,  not  only  from  the  gonococcus,  but 
from  the  bacillus  coli,  the  stapylococcus,  the  strep- 
tococcus, etc.,  all  or  any  of  which  may  be  present  in 
the  secretion,  may  arise.  These  organisms,  which  are 
probably  living  as  saprophytes  in  the  exudation,  can 
readily  play  a  different  role  if  they  gain  access  to  the 
placental  site  of  a  puerperal  uterus.  Exterminate 
the  gonococcus  with  its  irritating  toxins,  the  in- 
flammatory secretion  is  no  longer  produced,  and 
in  the  absence  of  the  medium  on  which  the  sapro- 
phytes thrive  they  can  soon  be  dislodged  from 
the  vagina. 

The  plan  of  treatment  differs  in  no  way  from  that 
already  described,  but  the  whole  process  must  be 
carried  out  with  the  utmost  gentleness,  and  it  can, 
therefore,  only  be  entrusted  to  specially  trained 
nurses,  otherwise  over-manipulation  might  induce 
premature  labour. 

Complications. — Pregnancy  tends  to  increase  the 
incidence  and  the  acuteness  of  gonorrhceal  rheu- 
matism and  the  other  metastatic  complications. 

Condylomata  acuminata. — Large  masses  may  ap- 
pear within  a  few  weeks.  Pregnancy  favours  the 
formation  of  these  growths.  Sometimes  they  de- 
velop into  large  cauliflower  excrescences.  These 
usually  consist  of  three  or  four  main  clumps  with 
enormous  numbers  of  small  warts  scattered  over  the 
vulvar  skin  and  mucous  membranes.  They  may  be 
found  on  the  vaginal  wall  and  cervix,  and  are  fre- 
quently found  around  the  anus,  suggesting  rectal 
gonorrhoea.  Their  treatment  is  dealt  with  in  a 
following  chapter. 

Gonococcal  infection  of  the  placenta  has  been  demon- 
strated as  a  cause  of  miscarriage,  and  penetration  of 


284    GONORRHOEA  &  ITS  COMPLICATIONS 

the  gonococcus  into  the  amniotic  fluid  is  a  rare  cause 
of  prenatal  destruction  of  the  infant's  eyes. 

The  gonococcus  in  the  puerperium. — The  onset  of 
gonococcal  endometritis  after  delivery  is  evidenced 
by  fever,  a  muco-purulent  element  in  the  discharge, 
and  inhibition  of  uterine  resolution.  It  usually 
asserts  itself  about  the  fourth  or  fifth  day,  and  runs  a 
comparatively  mild  course  unless  complicated  by  the 
intrusion  of  other  pyogenic  organisms.  Unless  pre- 
ventive measures  have  been  adopted,  a  mixed  in- 
fection may  arise,  or  even  more  likely  is  the  subjuga- 
tion of  the  gonococcus,  so  far  as  the  upper  genital 
tract  is  concerned,  by  the  most  active  of  the  organisms 
following  the  gonococcus  in  the  cervix,  commonly  a 
streptococcus.  Only  microscopic  and  cultural  ex- 
amination can  ensure  a  correct  diagnosis,  but  the 
type  of  inflammation  to  which  the  gonococcus  acting 
alone  gives  rise  is,  as  a  rule,  mild,  and  controllable 
with  purely  expectant  treatment. 


CHAPTER   XVll 

GONOCOCCAL   VULVO-VAGINITIS    IN   CHILDREN 

VuLVO-VAGiNAL  inflammation  in  children  has  long 
been  known  as  being  of  frequent  occurrence,  but  this 
condition  has  received  little  serious  attention  until 
recent  years.  Pott,  of  Halle,  in  reporting  an  epidemic 
in  1883,  recognised  the  contagious  character  of  the 
complaint,  but  not  its  association  with  the  gonococ- 
cus  as  the  causative  organism.  An  outbreak  in  Posen 
during  the  month  of  August,  1890,  was  investigated 
by  Skutsch,  who  found  that  236  girls  had  contracted 
gonococcal  infection  in  a  public  bath.  Many  instances 
in  which  the  disease  has  spread  through  dormitories, 
wards,  and  institutions  have  since  been  recorded. 
Once  infection  gains  admission  to  a  children's  institu- 
tion, so  much  trouble  is  experienced  in  controlling 
and  stamping  out  the  epidemic  that  in  many  hospitals 
the  rule  is  enforced  that  every  female  child  is  to  be 
examined  for  vaginal  pus  and  gonococci  before  ad- 
mission to  the  general  wards.  Where  search  has  been 
made  at  children's  clinics  for  cases  of  gonococcal 
vulvo-vaginitis,  it  has  been  found  to  be  present  in 
from  2  to  12  per  cent  of  the  female  children, 
the  general  average  being  about  4  per  cent  of  all 
applicants  for  medical  or  surgical  treatment. 

Etiology. — Every  case  of  vulvo-vaginal  inflamma- 
tion is  not  due  to  the  gonococcus.  Thus,  the  pneu- 
mococcus  has  been  proved  in  occasional  cases  to  be 
the  causative  agent,  but  the  condition  is  then  not 

285 


286    GONORRHCEA  &  ITS  COMPLICATIONS 

nearly  so  intractable.  The  irritation  of  thread-worms 
in  the  rectum  may,  in  ill-nourished  children,  give  rise 
to  inflammatory  conditions  in  which  various  organisms 
thrive.  Diphtheria  may  attack  the  vulvar  mucous 
membrane,  when  it  is  usually  in  association  with 
diphtheria  of  the  fauces  or  nasal  cavity.  But  these 
are  exceptional  cases.  The  vast  majority  of  cases 
of  vulvo-vaginitis  is  due  to  the  gonococcus. 

In  epidemic  form  the  disease  is  spread  by  bath 
water,  chambers,  closet  seats,  towels,  bed  linen,  rectal 
thermometers,  attendants'  hands,  etc.  In  individual 
cases  infection  is  incurred  from  adult  members  of  the 
family.  The  horrible  superstition  surviving  amongst 
the  ignorant  and  vicious  that  contact  with  an  im- 
mature vulva  will  ensure  cure  of  a  urethritis  is  un- 
fortunately still  responsible  for  a  quota  of  innocent 
victims. 

Anatomy  and  physiology. — In  young  children  the 
course  of  the  disease  is  influenced  by  the  absence  of 
the  vaginal  flora,  the  tender  and  non-resistant  epi- 
thelial surfaces,  and  the  absence  of  menstruation. 
The  bacillus  of  Doderlein  does  not  make  its  appear- 
ance in  the  vagina  until  the  approach  of  puberty,  and 
the  epithelium  of  the  vulva  and  vagina  prior  to  its 
advent  are  both  very  susceptible  to  gonococcal  in- 
flammation, in  this  respect  differing  from  the  adult 
mucous  membrane.  The  normal  mucous  membrane 
of  the  vulva  and  vagina  is  pink  and  slightly  moist. 
On  each  side  of  and  below  the  urethra  a  variable 
number  of  gland  openings,  in  addition  to  the  ducts  of 
the  Bartholin  glands,  are  seen,  and  small  recesses  or 
para-urethral  passages  are  not  uncommon.  The 
vagina  is  from  1 J  to  2  J  inches  in  length.  The  cervix  is 
nipple-shaped  and  fairly  constant  in  size,  contributing 
about  half  the  bulk  of  the  uterus.    The  external  os  is 


VULVO-VAGINITIS   IN    CHILDREN     287 

a  minute  circular  or  transverse  opening  too  small  to 
admit  an  ordinary  probe. 

A  long-continued  vulvo-vaginitis  tends  to  hasten 
the  development  of  the  organs  of  sex  owing  to  the 
increased  blood  supply  of  the  parts. 

Symptoms. — The  inflammation  produced  by  the 
activity  of  the  gonococcus  is  an  acute  process.  It 
spreads  with  great  rapidity  from  the  vulva  to  the 
vagina  and  cervix  as  well  as  to  the  urethra.  On  in- 
spection, the  whole  exposed  mucous  surface  is  seen 
to  be  reddened  and  bathed  in  creamy  pus.  In  the 
early  stage,  the  parts  are  tender  to  touch,  and  the 
neighbouring  skin  may  be  excoriated  by  contact  with 
the  irritating  discharge.  In  cases  which  are  controlled 
by  frequent  cleansing,  pus  can  be  seen  to  well  from 
the  vagina  on  the  patient  making  straining  efforts,  or 
it  can  be  collected  on  a  wool- wrapped  probe. 

As  in  the  adult,  the  main  sites  of  gonococcal  se- 
clusion are  the  vulval  glands,  including  the  glands  of 
Bartholin,  the  urethra  and  Skene's  ducts,  and  the 
cervix.  But  in  children,  the  vaginal  walls,  although 
free  from  glandular  structures,  are  affected  by  the 
inflammatory  process,  many  small  red  areas  where 
gonococcal  invasion  has  occurred  being  seen  on  the 
vaginal  walls  when  the  coating  of  sero-pus  has  been 
removed.  The  hymen  opposes  no  obstacle  to  the 
upward  spread  of  the  disease,  and  apart  altogether 
from  instrumental  or  other  mechanical  conveyance  of 
the  infection,  the  disease  can,  and  does  in  most  cases, 
reach  the  cervix,  from  which  it  is  most  difficult  to  dis- 
lodge. The  only  check  to  the  onward  progress  of  the 
inflammatory  process  is  provided  by  the  internal  os, 
and  that  this  barrier  is  not  infrequently  overcome  is 
evidenced  by  the  onset  of  salpingitis  and  peritonitis  in 
some  cases. 


288     GONORRHCEA  &  ITS  COMPLICATIONS 

Diagnosis. — In  the  most  severe  cases  the  whole 
vulvar  mucosa  is  seen  to  be  inflamed.  In  less  acute 
cases  and  in  chronic  conditions  the  reddening  is  con- 
fined to  the  everted  urethra,  isolated  areas  of  the 
mucous  membrane,  and  gland  ducts  or  recesses.  Soon 
after  cleansing,  pus  will  be  observed  to  reappear  at 
the  vaginal  orifice  if  expulsive  efforts  are  invoked. 
The  presence  of  secretion  and  detritus,  especially  in 
the  region  of  the  clitoris,  is  not  uncommon  in  neglected 
children,  but  in  uninfected  cases  the  stigmata  of 
gonorrhoea  are  absent,  and  there  is  no  deep  vaginal 
or  urethral  pus.  Although  with  experience  the  con- 
dition can  often  be  diagnosed  by  inspection  alone 
even  in  the  temporary  absence  of  pus,  nevertheless 
both  the  diagnosis  and  the  treatment  must  be  con- 
trolled by  bacteriological  examination.  At  the  first 
examination,  several  smears  should  be  taken  by 
means  of  sterile  wool-wrapped  probes  or  platinum 
spoons  and  in  the  following  sequence  :  (1)  From  the 
vulva,  after  superficial  cleansing  with  dry  wool  or 
plain  water ;  (2)  from  the  urethra,  after  thorough 
purification  of  the  vulva  ;  (3)  from  the  vagina  ;  (4) 
from  the  cervix,  after  as  complete  sterilization  of  the 
vagina  as  possible.  To  obtain  the  fourth  specimen  it 
is  necessary  to  display  the  cervix,  and  this  can  usually 
be  done  without  difficulty  by  means  of  a  female  ure- 
throscope. An  instrument  provided  with  a  reflected 
light,  or  an  ordinary  Kelly  cystoscopic  tube  with  a 
head  mirror  may  be  used,  but  the  best  illumination  is 
obtained  with  an  internally  lit  apparatus.  It  is  an 
advantage  to  have  the  ends  of  the  tubes  cut  obliquely 
as  in  the  Ferguson  speculum.  A  tube  of  suitable 
size  is  chosen,  and  with  its  obturator  in  position  is 
passed  as  far  as  possible  into  the  vagina  and  the 
obturator  is  withdrawn.     By  rotating  the  urethro- 


VULVO-VAGINITIS    IN    CHILDREN     289 

scope  and  tilting  it  backwards,  the  cervix  will  be 
enticed  into  the  tube,  and  with  a  very  fine  probe  the 
secretion  is  secured  for  the  smear.  Before  with- 
drawing the  instrument  the  condition  of  the  cervix 
and  the  nature  of  the  discharge  is  noted.  Search  is 
made  for  erosions  of  the  cervix  and  adhesions  about 
the  vault  of  the  vagina.  As  the  tube  is  withdrawn  the 
vaginal  walls  are  inspected  for  reddened  and  infil- 
trated areas  or  infected  crevices.  As  a  rule  the 
gonococcus  is  present  in  each  of  the  smears  from  an 
infected  site  in  considerable  numbers,  and  they  are 
more  readily  recognised  in  these  smears  than  in 
specimens  obtained  from  the  adult  female  on  account 
of  the  paucity  of  contaminating  organisms.  The 
gonococcus  is  frequently  obtained  in  pure  culture 
from  the  upper  part  of  the  vagina  and  from  the  cervix. 
Complications. — Gonococcal  infection  of  the  uro- 
genital tract  in  young  girls  is  liable  to  the  same 
complications  and  sequelae  as  in  the  adult  female. 
Abscess  of  the  glands  of  Bartholin  is  said  to  be  un- 
common, but  according  to  my  experience  it  occurs  in 
much  the  same  ratio  as  in  adults.  The  Fallopian 
tubes  are  also  liable  to  be  involved,  but  the  risk  of 
this  extension  is  somewhat  less  than  in  the  adult  on 
account  of  the  absence  of  menstruation.  When  the 
peritoneal  cavity  is  contaminated  through  the  tubes, 
the  resulting  peritonitis  tends  to  become  localised 
in  definite  areas  in  the  pelvis  and  a  rapid  recovery  is 
the  rule.  A  case  is  sometimes  met  with,  however, 
where,  owing  to  the  weak  resisting  power  of  the 
patient  or  to  hypervirulence  of  the  particular  strain 
of  gonococcus,  the  inflammatory  process  spreads  with 
great  rapidity,  and  the  general  cavity  of .  the  peri- 
toneum becomes  involved  before  adhesions  can  be 
formed  to  limit  the  disease.    Also,  the  rupture  of  an 

WATSON. —  U 


290    GONORRHCEA  &  ITS  COMPLICATIONS 

acute  salpingitis  may,  by  scattering  foci  of  infection 
throughout  the  abdomen,  give  rise  to  an  acute  general 
peritonitis.  But  it  should  be  remembered  that  the 
tendency  in  the  great  majority  of  cases  of  invasion 
of  the  peritoneum  by  a  pure  gonococcus  infection  is 
in  the  direction  of  localised  areas  of  inflammation 
with  the  formation  of  protecting  adhesions,  and  that 
operation  is  therefore  not  only  not  obligatory,  but, 
during  the  active  stage  at  least,  is  inadvisable. 

Rheumatism  of  a  mild  type  is  not  uncommon,  and 
in  occasional  cases  it  may  be  acute.  Ophthalmia  may 
be  due  to  infection  by  the  blood  stream  in  which 
case  it  is  not  severe,  or  an  acute  attack  may  be  pro- 
duced by  manual  transference  of  the  organism  to  the 
conjunctiva.  The  risk  of  the  latter  must  be  antici- 
pated and  measures  of  prevention  adopted. 

Prognosis. — The  outlook  as  regards  rapid  and 
permanent  cure  is  not  good.  Relapses  are  to  be 
expected,  and  bacteriological  examinations  must  be 
made  at  regular  intervals  over  a  period  of  months. 
As  long  as  the  gonococcus  remains  in  the  genital 
tract  the  patient  is  liable  to  an  attack  of  salpingitis 
with  its  sequelae  of  adhesions  and  later  interference 
with  the  menstrual  function. 

Treatment. — The  treatment  of  gonococcal  infection 
in  young  girls  is  attended  with  much  more  difficulty 
than  in  adult  females  and  is  too  often  disappointing. 
This  is  due  not  only  to  the  difficulty  of  reaching  the 
infected  areas,  but  to  the  greater  susceptibility  of  the 
epithelial  surfaces  and  the  less  satisfactory  drainage. 
Prophylaxis  is  therefore  of  the  utmost  importance 
both  for  the  purpose  of  avoiding  infection  and  pre- 
venting reinfection  when  cure  has  been  attained. 
Isolation  of  each  case  from  other  children  is  the  safest 
course,  but  this  is  seldom  obtainable  in  practice. 


VULVO-VAGINITIS   IN    CHILDREN     291 

It  should  be  a  notifiable  disease,  and  under  the  con- 
trol of  the  health  authorities,  who  would  supply 
hospital  treatment  for  cases  which  could  not  be 
satisfactorily  treated  and  isolated  at  home. 

^Vhether  treated  in  hospital  or  at  home,  the  case 
should  be  in  the  hands  of  specially  trained  nurses 
under  medical  supervision.  The  hospital  arrange- 
ments should  permit  of  each  patient  having  a  separate 
cubicle  partitioned  off  from  the  wards  with  sufficient 
glass  in  the  walls  to  allow  of  constant  observation. 
No  toilet  article  should  under  any  circumstances  be 
shared  with  another. 

The  patient  should  not  be  bathed  (unless  a  shower 
bath  is  obtainable),  but  daily  sponging  should  be 
relied  on  to  secure  cleanliness,  the  genital  region 
receiving  prior  attention  with  a  different  outfit  and 
being  carefully  avoided  during  the  general  sponge. 
Gauze  sponges  should  be  employed,  and  destroyed 
after  use.  All  toilet  articles  should  be  sterilized  daih^ 
by  heat.  The  common  laundry  is  not  a  source  of 
danger,  and  separate  treatment  of  the  linen  is  not 
necessary. 

The  children  may  be  allowed  up  and  out  of  doors, 
but  always  under  the  eye  of  the  nurse.  They  should 
wear,  in  addition  to  a  sanitary  towel,  closed  knicker- 
bockers so  fashioned  that  they  can  only  be  undone  by 
the  nurse. 

The  nurse  should  approach  the  parts  invariably  with 
gloved  hands,  and  she  should  steep  the  hands  in  anti- 
septic and  dry  carefully  thereafter  or  wear  fresh 
gloves  for  each  case.  A  thermometer  should  never 
be  inserted  into  the  rectum.  The  use  of  water- 
closets  should  be  entirely  forbidden.  The  removal 
of  the  anterior  portion  of  the  seat  or  applying  a 
fresh  layer  of  paper  as  a  protection  does  not  remove 


292    GONORRHCEA  &  ITS  COMPLICATIONS 

the  objection,  as  the  splashing  of  a  drop  of  water 
from  the  pan  may  mean  reinfection. 

The  same  principles  of  treatment  apply  in  the  case 
of  children  as  in  adults,  viz.,  local  cleansing  and 
application  of  gonococcal  antiseptics,  and  such  general 
treatment  as  will  raise  the  resisting  power  of  the 
system. 

The  vulva  can  be  cleansed  by  swabbing  or  by 
sitz  baths,  the  vagina  by  swabbing  or  douching,  and 
the  infected  areas  must  be  soaked  with  an  unirritating 
silver  solution.  When  a  douche  is  used  the  end  piece 
or  catheter  should  enter  the  vagina  at  least  1 J  inches. 
Saline  solution  or  an  antiseptic  solution  may  be  used 
e.g.,  permanganate  of  potash  (1  in  2000) ;  boric 
acid  (saturated  solution) ;  lactic  acid  (1  per  cent). 
The  solution  should  be  as  warm  as  the  child  can  bear. 
But  douching  alone  can  never  effect  a  cure  ;  the  im- 
portant part  of  the  treatment  is  the  application  of 
a  silver  preparation  to  the  infected  sites.  Having 
ascertained  to  what  extent  the  infection  has  spread 
(and  in  most  cases  each  possible  location  will  be 
found  to  be  infected),  attention  has  to  be  directed  to 
each  region.  The  smallest  urethroscopic  tube  is  in- 
serted into  the  urethra  just  short  of  the  bladder,  when 
a  wool-wrapped  probe  saturated  with  the  chosen 
silver  solution  can  be  passed  into  the  tube,  the  ure- 
throscope withdrawn,  and  the  probe  left  in  situ  for 
a  few  minutes.  The  cervix  is  displayed  through  a 
larger  tube  of  the  female  urethroscope,  and  by  means 
of  a  very  slender  probe  a  similar  application  is  made 
to  the  cervix,  care  being  taken  that  the  internal  os  is 
not  penetrated.  The  vagina  is  swabbed  with  the 
solution,  and  a  layer  of  lint  wet  with  the  silver  is  left 
between  the  lips  of  the  vulva  for  some  time. 

The  choice  of  the  silver  preparation  is  important. 


VULVOVAGINITIS   IN   CHILDREN     293 

An  efficient  colloid  such  as  "  Colossal  Argentum " 
gives  good  results  and  is  quite  unirritating.  Protargol 
in  glycerine  is  warmly  recommended  by  Perrin,  of 
Lausanne  (protargol,  5-0;  distilled  water,  8-0;  glyce- 
rine to  50-0  parts). 

Pessaries  of  the  lactic  acid  bacillus  in  lactose  do 
not  give  the  same  satisfactory  results  as  in  the  adult, 
but  they  are  nevertheless  of  considerable  value, 
especially  in  the  older  children.  They  can  be  crushed 
and  inserted  as  powder  through  the  urethroscope  a 
few  hours  after  the  silver  treatment. 

Treatment  should  be  continued  daily  until  the 
gonococcus  is  permanently  absent  from  the  smears. 

Vaccine  therapy  in  vulvo- vaginitis  has  been  the 
subject  of  some  enthusiastic  reports  ;  but  in  my 
hands  it  has  not  so  far  proved  of  value  ;  indeed,  in 
some  cases  it  seemed  to  determine  a  recurrence,  and 
in  others  to  invite  complications. 


CHAPTER  XVIII 

CONDYLOMATA   ACUMINATA  i 

(venereal  warts) 

Warty  growths  are  a  not  infrequent  accompaniment 
of  gonorrhoeal  infection,  especially  in  patients  who 
have  an  insufficient  appreciation  of  the  advantages 
of  personal  cleanliness.  The  vegetations  may  vary 
in  size  from  a  pin-point  to  a  cauliflower  mass.  They 
adopt  the  physical  characteristics  of  the  tissue  from 
which  they  spring,  whether  mucous  membrane  or 
skin  ;  but  they  all  have  essentially  the  same  histo- 
logical structure.  The  sites  most  favoured  by  these 
growths  are,  in  the  male,  the  inner  surface  of  the 
prepuce,  the  coronal  sulcus,  the  meatus  urinarius, 
and  the  surface  of  the  glans.  A  considerable  growth 
within  the  sac  of  a  tight  prepuce  may  give  rise  to 
sloughing  and  sinus  formation,  or  a  strawberry  mass 
may  project  from  the  preputial  orifice.  In  women 
the  areas  most  prone  to  be  affected  are  the  inner  and 
outer  surfaces  of  the  labia,  the  base  of  the  clitoris, 
the  vaginal  walls,  the  cervix,  and  also  around  the 
anal  orifice.  Pregnancy  favours  the  formation  of 
large  masses,  owing  probably  to  the  increased  vascu- 
larity of  the  parts. 

Condylomata  acuminata  occur  more  frequently  in 
women  than  in  men,  and  in  the  female  they  attain 
much  greater  dimensions.     Large  cauliflower  masses 

1  This  article  first  appeared  in  the  "Lancet/'  ISth  April,  1912. 

294 


PLATE  XII. 


•w;^ 


Section  of  Condyloma  Acuminatum  stained  with  Haematein  and  Eosin. 


CONDYLOMATA   ACUMINATA         295 

may  cover  the  vulva  and  perineum,  while  numbers 
of  small  warts  occupy  the  adjacent  skin  and  mucous 
surfaces.  So  long  as  they  remain  untreated  they  are 
kept  moist  by  an  offensive  secretion  containing  the 
detritus  of  macerated  epithelial  and  pus  cells  and 
numerous  micro-organisms. 

Histologically,  they  are  composed  of  elongated 
branching  papillae,  covered  with  an  enormously 
thickened  epithilium.     The  papillae  are  supplied  with 


Fig.  to. 
Vulvo-anal  masses  of  condylomata  acmninata. 

capillary  loops,  surrounding  which  are  frequent 
patches  of  small  round-celled  infiltration.  Special 
nerve  endings  found  in  the  epithelial  layer  are  con- 
nected with  a  fine  network  of  nerve  fibres  in  the 
base  of  the  papillae.  The  main  bulk  of  the  hyper- 
trophy is  due  to  the  rapid  proliferation  of  the  swollen 
cells  of  the  Malpighian  la\xr,  which  is  therefore 
greatly  increased  in  thickness.  Between  these  epi- 
thelial cells  numerous  mononuclear  and  polynuclear 
wandering  cells  are  found.  The  surface  cells  which 
form  the  thin  horny  layer  tend  to  undergo  mace- 
ration   and    desquamation,     and     minute    areas    of 


296    GONORRHCEA  &  ITS  COMPLICATIONS 

necrosis  allow  of  serous  and  sometimes  haemorrhagic 
oozing. 

The  customary  association  of  condylomata  acu- 
minata with  gonorrhoea  naturally  suggests  that  the 
formation  of  these  growths  is  induced  by  the  irrita- 


FiG.  71. 
Condylomata  acuminata  of  prepuce  and  glans. 

tion  of  the  gonorrhoeal  discharge.  The  gonococcus 
has  not  been  demonstrated  in  sections  ;  but  other 
organisms  such  as  streptococci,  staphylococci,  and 
more  recently  spirilla  have,  of  course,  been  found. 
Whether  these  papillary  hypertrophies  are  the  pro- 
duct merely  of  a  mechanical  irritation  or  whether 
they  owe  their  existence  to  the  action  of  some  specific 


CONDYLOMATA    ACUMINATA         297 

organism,  acting  on  a  suitably  prepared  soil,  is  a 
problem  still  awaiting  solution. 

Treatment. — The  treatment  which  conspicuously 
suggests  itself  for  all  condylomata  acuminata  is  ex- 
cision with  suture  of  the  wound  under  local  anaes- 
thesia. Ligature  of  each  portion  separately  or 
destruction  by  the  use  of  caustics  and  cauteries  are 
only  mentioned  to  be  dismissed  as  barbarous  both 
in  use  and  effect. 

But  even  excision  has  disadvantages  which  prevent 
it  from  being  of  universal  application.  AMien  large 
masses,  such  as  are  not  infrequently  found  in  females, 
have  to  be  dealt  with  a  general  anaesthetic  is  required, 
and  from  one  to  two  hours  may  be  employed  in  re- 
moving several  separate  cauliflower  excrescences  as 
well  as  numbers  of  smaller  growths.  The  time  is 
mostly  occupied  in  controlling  haemorrhage  from  the 
very  numerous  bleeding-points.  When  the  most 
thorough  removal  possible  has  been  effected  and  the 
remaining  skin  and  mucous  surfaces  examined,  these 
are  found  to  be  seeded  with  minute  papillary  vegeta- 
tions, which  one  is  tempted  to  treat  with  the  thermo- 
cautery while  the  patient  is  still  under  the  anaesthetic. 
The  latter  procedure  is  worse  than  useless,  as  it 
destroys  only  a  fraction  of  the  minute  growths, 
healing  is  painful  and  slow,  and  the  results  of  the 
cicatricial  deformity  may  be  deplorable,  involving 
perhaps  loss  of  the  sexual  function  or  control  of  the 
bladder.  But  even  when  the  temptation  to  use  any 
cauterizing  procedure  is  resisted  the  result  will  be 
disappointing.  Recurrence,  not  of  large  masses  but 
of  numerous  smaller  vegetations,  is  certain  ;  all  of  the 
wounds  will  not  heal  by  primary  union  as  the  mainte- 
nance of  a  clean  field  is  impossible,  and  one  cannot 
foresee    what    will   be   the   ultimate    results    of   the 


298    GONORRHCEA  &  ITS  COMPLICATIONS 

cicatricial  contraction.  If,  then,  there  are  other 
methods  of  treatment  which  have  any  prospect  of 
success  they  demand  careful  consideration.  Several 
procedures  have  been  advocated  ;  formalin  applied 
to  small  areas  at  a  time  is  effective,  but  slow  and  very 
painful,  for  which  reason  I  have  had  to  discard  it ; 
carbolic  acid  and  chromic  acid  are  useful  in  the  case 
of  small  growths,  and  are  most  effective  when  used 
alternately,  but  both  of  these  poisons  must  be  used 
with  caution  ;  resorcin  and  starch  in  equal  propor- 
tions make  a  useful  paste,  but  it  is  difficult  sufficiently 
to  localise  its  action,  and  inflammatory  irritation  may 
be  produced  ;  salicylic  acid,  1  per  cent,  in  precipitated 
chalk  is  recommended  by  Taylor  as  a  dusting  powder  ; 
chloral  hydrate  solution  (1  in  8)  has  been  suggested 
as  a  paint ;  tincture  of  iodine  is  another  application 
which  has  its  advocates.  In  my  experience,  however, 
the  treatment  which  has  been  found  to  be  most 
simple,  effective,  and  free  from  objection  is  the 
application  of  lactic  acid.  The  mode  of  employment 
Tvill  depend  upon  the  condition  present.  In  the 
male  circumcision  is  performed  when  necessary, 
pedunculated  warts  may  be  removed  with  scissors, 
and  pure  lactic  acid  applied  to  the  base  after  the 
bleeding  has  been  controlled.  Other  growths  are 
treated  with  a  continuous  1  per  cent  wet  dressing  or 
the  occasional  application  of  a  strong  solution.  In 
the  female,  when  there  are  several  large  masses,  each 
portion  is  isolated  and  kept  surrounded  by  strips  of 
lint  wet  with  a  |-  to  1  per  cent  solution.  The  base  of 
these  growths  may  in  addition  be  touched  at  intervals 
of  a  few  days  with  the  pure  acid.  Smaller  growths 
are  painted  with  the  undiluted  acid  or  a  strong 
solution,  and  when  there  is  a  large  field  of  minute 
growths  the  wet  dressing  is  employed.    The  dressings 


CONDYLOMATA   ACUMINATA         299 

are  changed  as  frequently  as  the  amount  of  discharge 
necessitates,  and  at  each  change  the  parts  are 
thoroughly  bathed  with  an  antiseptic,  in  the  case 
of  females  a  sitz  bath  being  used.  The  largest  masses 
wither  and  drop  off,  small  growths  are  inhibited,  and 
cure  results  without  the  formation  of  any  cicatrices 
and  without  pain.  The  only  disadvantage  I  have 
encountered  in  the  use  of  lactic  acid  is  the  occasional 
occurrence  of  a  general  ervthema  when  the  treatment 
is  pushed  too  energetically.  This  erythema  is  of 
trifling  significance,  and  quickly  subsides  on  the 
temporary  withdrawal  of  the  acid  and  the  substitu- 
tion of  a  zinc  and  calomel  dusting  powder  or  ointment. 
On  this  account,  however,  it  may  be  necessary  when 
large  areas  are  involved  to  intermit  the  treatment 
for  two  days  in  each  week,  and  to  protect  the  sur- 
rounding healthy  tissues  with  vaseline  in  order  to  dis- 
courage excessive  absorption  of  the  acid.  As  soon  as 
the  seats  of  gonorrhoea]  infection — urethra,  cervix, 
rectum,  etc. — can  be  reached  appropriate  treatment 
is  initiated,  and  this,  combined  with  strict  cleanli- 
ness, has  an  important  influence  in  preventing  the 
appearance  of  fresh  growths. 

The  histories  of  a  few  cases  kindly  furnished  me 
by  Sister  Frisby,  of  the  Glasgow  Lock  Hospital,  will 
illustrate  the  method  and  its  results. 

Case  1. — The  patient,  aged  thirteen,  was  admitted 
on  September  1st,  1910,  suffering  from  gonorrhoea 
and  medium-sized  warty  growths  in  the  anal  region. 
The  warts  were  treated  by  cyllin  sitz  baths  three 
times  daily  and  application  of  pure  lactic  acid  once 
daily.  In  four  days  the  warts  began  to  imj^rove,  and 
they  had  completely  disappeared  in  twelve  days. 
Patient  was  dismissed  on  September  16th. 

Case  2. — The  patient,  aged  twenty-one,  five  months 


300    GONORRHCEA  &  ITS  COMPLICATIONS 

pregnant,  was  admitted  on  August  22nd,  1910,  with 
gonorrhoea  and  numerous  warty  vegetations  on  the 
skin  and  mucous  surfaces  of  the  labia  majora.  Con- 
tinuous wet  dressing  of  1  per  cent  lactic  acid  was 
employed.  Improvement  was  manifest  on  August 
27th,  and  completed  on  September  8th.  Patient 
was  dismissed  on  September  10th. 

Case  3. — The  patient,  aged  nineteen,  w^as  admitted 
on  September  5th,  1910,  suffering  from  gonorrhoea 
and  condylomata  acuminata.  Large  masses  covered 
the  vulva  and  perineum  and  extended  beyond  the 
anus.  The  whole  growth  was  as  large  as  a  medium- 
sized  cauliflower.  The  patient  at  first  had  to  be 
isolated  on  account  of  the  very  offensive  odour. 
She  had  been  previously  treated  for  a  short  time  in 
another  hospital.  The  growth  had  appeared  and 
grown  with  great  rapidity  three  months  before  ad- 
mission. After  being  cleaned  up  with  a  J  per  cent 
lactic  acid  solution  the  masses  were  separately  sur- 
rounded with  strips  of  lint  soaked  in  1  in  100  lactic 
acid.  In  two  days  portions  began  to  drop  off,  and 
in  seven  weeks  all  traces  had  disappeared  without 
the  formation  of  any  cicatrices  whatever. 

These  cases  sufficiently  indicate  the  lines  of  treat- 
ment and  the  results  to  be  expected  in  most  in- 
stances ;  but  certain  varieties,  especially  where 
complicated  with  syphilis  or  tuberculosis,  are  more 
resistant.  The  only  claim  I  make  for  this  treatment 
is  that  it  is  the  most  generally  satisfactory  of  the 
many  systems  with  which  I  have  experimented. 


CHAPTER   XIX 

GONOCOCCAL  CYSTITIS 

There  is  little  doubt  that  in  practically  all  cases 
of  posterior  urethritis  the  bladder  is  exposed  to  in- 
fection by  the  pus  overflowing  from  the  posterior 
urethra,  but  the  epithelium  of  the  bladder  shows  a 
considerable  resistance  to  attack  by  the  gonococcus, 
and  cystitis  is  accordingly  a  comparatively  rare 
complication  of  gonorrhoea. 

The  condition  is  more  easily  demonstrated  in  the 
female,  as  there  is  not  the  same  objection  to  the  use 
of  the  cystoscope.  In  a  recent  case  of  my  own 
occurring  in  a  young  woman,  during  the  course  of 
a  gonorrhoeal  infection  attention  was  drawn  to  the 
bladder  b}^  the  amount  of  pus  in  the  urine  and  the 
enormous  numbers  of  gonococci  in  the  urethral  smear. 
Cystoscopic  examination  of  the  bladder  showed  a 
number  of  small,  raised,  bright  red  areas  limited  in 
distribution  to  the  trigone.  Swabs  taken  from  these 
spots  gave  a  pure  growth  of  gonococci. 

Superinfection  with  other  organisms,  particularly 
the  bacillus  coli,  streptococcus,  or  staphylococcus,  is 
prone  to  occur,  and  on  that  account  and  also  because 
of  its  painfulness  in  acute  conditions  and  the  danger 
of  inducing  complications,  cystoscopy  is  not  advisable 
as  a  routine  procedure.  The  gonococcus  does  not 
cause  ammoniacal  decomposition. 

Characteristic  symptoms  are  difficult  to  find.    Some 

301 


302    GONORRHCEA  &  ITS  COMPLICATIONS 

of  the  symptoms  produced  by  the  concurrent  pos- 
terior urethritis  may  be  accentuated,  e.g.,  urinary 
tenesmus  and  frequency  of  micturition  ;  but,  on  the 
other  hand,  these  symptoms  may  not  be  prominent. 
A  dull  bladder  pain  felt  over  the  symphysis  is  frequently 
complained  of.  If  there  is  any  vesical  haemorrhage 
the  blood  is  intimately  mixed  with  the  urine,  and 
has  not  the  terminal  character  of  the  hsematuria  of 
posterior  urethritis. 

Some  rise  in  temperature  and  a  feeling  of  malaise 
are  generally  present.  Assistance  in  diagnosis  is  got 
from  the  three-glass  test,  but  only  if  applied  a  short 
time  after  a  previous  emptying  of  the  bladder.  In 
such  a  case  the  pus  produced  in  the  posterior  urethra 
will  not  have  accumulated  in  sufficient  quantity  to 
have  overcome  the  resistance  of  the  internal  sphincter 
and  reach  the  bladder,  and  therefore  will  be  dis- 
charged with  the  foremost  urine  into  the  first  glass. 
Pus  in  the  second  glass  is  therefore  suggestive  of 
cystitis.  The  third  glass,  usually  considered  the 
prostatic  glass,  is  oiten  very  turbid,  as  in  addition  to 
prostatic  pus  it  may  contain  sedimentary  pus  from 
the  bladder,  or,  as  Scholtz  suggests,  pus  adhering  to 
the  bladder  walls  expressed  by  the  final  contraction 
of  the  bladder. 

Treatment. — A  copious  flow  of  bland  urine  with 
frequent  emptying  of  the  bladder  even  at  night 
should  be  encouraged.  Atropine  should  be  given  to 
prevent  reversed  peristalsis  and  as  a  sedative.  Bal- 
samics  and  urinary  antiseptics  combined  with  uvse 
ursi  or  buchu  are  useful.  Especially  valuable  are 
urotropine  and  sandalwood  oil.  Unless  contra- 
indicated  the  bladder  should  be  flushed  out  by  the 
Janet  method,  using  a  silver  solution  such  as  1-4000 
silver  nitrate. 


GONOCOCCAL    CYSTITIS  303 

Should  the  case  prove  obstinate  and  the  cysto- 
scope  show  areas  requiring  stimulation,  stronger 
solutions  may  be  instilled. 

The  female  bladder  is  less  exposed  to  the  risk  of 
infection,  there  being  no  backward  flow  of  con- 
taminated pus,  but  cases  do  arise  in  practice.  Medi- 
cinal treatment  should  be  given  a  fair  trial.  There- 
after recourse  may  be  had  to  lavation,  and  finally,  if 
necessary,  affected  areas  may  be  treated  directly 
through  a  Kelly  cystoscope  with  strong  silver  solu- 
tions. 


CHAPTER  XX 

GONOCOCCAL   INFECTION   OF  THE   KIDNEY 

There  are  three  paths  by  which  the  gonococcus  can 
reach  the  kidney  : — 

(1)  By  the  ureter  to  the  pelvis  of  the  kidney  from 

the  bladder  ; 

(2)  by  the  blood-stream  ; 

(3)  by  the  lympatic  system. 

(1)  Direct  extension  along  the  ureter  of  a  non-motile 
organism  like  the  gonococcus  presupposes  one  of  three 
conditions  or  a  combination  of  them,  viz., 
(a)  reversed  peristalsis  of  the  ureter  ; 
(h)  obstruction  to  the  urinary  outflow  distal  to  the 
bladder  and  damming  back  of  infected  urine  ; 
(c)  Infection   of   the   ureteral   mucosa   and   direct 
upward  extension  of  th6  gonococcal  inflam- 
mation ;    this  process  might  be  hastened  by 
ureteral  obstruction  with   the  production  of 
a  column  of  stagnating  urine. 
{2)  Infection  through  the  bloodstream. — The   possi- 
bility of  the  deposition  of  gonococci  in  any  part  of 
the  kidney  substance  from  the  circulating  blood  can 
be  readily  understood  in  view  of  the  frequency  of  the 
presence  of  the  organism  in  the  blood  and  the  quantity 
of  blood  which  is   constantly  filtering  through  the 
kidneys.     It  is  probable  that  gonococci  can  be  ex- 
creted through  the  kidneys  as  is  known  to  occur  with 
other  organisms,     The  comparative  rarity  of  kidney 

304 


INFECTION   OF   THE   KIDNEY         305 

infection  proves  therefore  that  the  kidney  tissues 
possess  an  inhibiting  action  on  gonococcal  activity. 
Infected  emboh  may  lodge  in  the  kidney  substance 
during  an  acute  septicaemia. 

(3)  Invasion  of  the  kidney  through  the  lymphatic 
system  is  just  a  possibility.  Free  intercommunica- 
tion of  the  lymphatic  plexures  surrounding  the  lower 
and  upper  segments  of  the  genito-urinary  tract  has 
been  demonstrated.  In  this  case  the  perinephritic 
region  would  be  the  first  to  be  reached.  One  case  of 
perinephritic  abscess  in  which  the  gonococcus  was 
found  has  been  described. 

Notwithstanding  the  difficulties  in  the  way  of  the 
organism  reaching  the  kidney  in  sufficient  numbers 
to  overcome  the  natural  defences  of  the  organ,  a 
sufficient  number  of  bacteriologically  proved  cases 
have  been  reported  to  establish  the  possibility  of  any 
given  case  of  kidney  disease  associated  with  a  gono- 
coccal infection  of  the  genital  tract  being  due  to 
gonococcal  nephritis  or  pyelitis. 

Gonococcal  pyelitis. — Over  twenty  cases  of  inflam- 
mation of  the  pelvis  of  the  kidney  diagnosed  as  being 
due  to  the  gonococcus  have  been  reported.  In  nearly 
half  of  these  papers  the  evidence  is  inconclusive,  a 
complete  bacteriological  examination  having  been 
unobtainable.  Lehr  publishes  an  account  of  a  care- 
fully authenticated  case  in  the  "  Journal  of  the 
American  Medical  Association,"  July  6th,  1912,  in 
which  he  remarks  that  "  this  complication  of  gonor- 
rhoea may  be  more  common  than  the  comparative 
scarcity  of  the  literature  would  indicate." 

Symptoms. — Pain,  which  may  be  paroxysmal  or 
continuous,  is  complained  of  in  the  region  of  the 
kidney  and  along  the  course  of  the  ureter.  Pyuria 
persisting  after  apparent  cure  of  the  lesions  in  the 


306    GONORRH(EA  &  ITS  COMPLICATIONS 

lower  uro-genital  tract  is  constantly  present.  The 
temperature  varies  from  normal  to  103°  F.,  and  the 
pulse  ranges  round  90. 

Diagnosis. — Diagnosis  can  only  be  assured  by 
finding  the  gonococcus  in  a  specimen  of  the  ureteral 
urine.  Frequently  there  is  a  mixed  infection.  Cysto- 
scopic  examination  usually  reveals  a  hypersemic 
condition  of  the  trigone,  and  small  red  areas  of  infil- 
tration, especially  round  the  orifice  of  the  affected 
ureter.  From  the  ureter  of  the  infected  side  purulent 
urine  will  be  seen  to  shoot,  while  from  the  sound 
ureter  the  escaping  urine  will  be  normal.  For  ex- 
amination purposes  the  urine  should  be  collected  by 
ureteral  catheter  from  the  diseased  side  only.  It 
seems  undesirable  to  introduce  a  catheter  through 
an  infected  bladder  into  an  apparently  sound  ureter, 
although  no  accidents  have  been  reported  as  a  result 
of  this  procedure. 

Tuberculosis  is  excluded  by  the  absence  of  the 
tubercle  bacillus  from  the  ureteral  urine  and  calculus 
by  X-Ray  examination. 

The  prognosis  is  good,  in  the  absence  of  septicaemia, 
if  treatment  is  not  too  long  delayed. 

Treatment. — Internal  medication  by  balsamics  and 
urinary  antiseptics,  along  w^ith  rest  in  bed  and  a  milk 
diet,  should  be  given  a  fair  trial.  In  the  event  of 
failure  on  these  lines,  lavage  of  the  kidney  pelvis 
through  the  ureteral  catheter  is  indicated.  A  solution 
of  one  of  the  organic  silver  preparations  may  be  used, 
or  preferably  a  1  in  1000  solution  of  silver  nitrate. 
At  each  sitting,  several  injections  should  be  given, 
beginning  with  5  cubic  centimetres  and  not  increasing 
beyond  10  cubic  centimetres ;  or  a  catheter  sufficiently 
fine  to  allow  of  a  free  return  flow  may  be  used,  and 
irrigation  with  200  cubic  centimetres  of  a  1  in  5000 


INFECTION   OF   THE    KIDNEY         307 

silver  nitrate  solution  adopted.  Irrigation  is  the 
superior  method,  and  the  strength  of  the  solution  can 
be  gradually  increased  up  to  1  in  2500. 

Pyelo-nephritis. — The  number  of  cases  of  pyelo- 
nephritis which  are  on  record  is  even  smaller  than  of 
pyelitis.  Pyelo-nephritis  is  probably  due  to  an 
extension  of  the  inflammation  from  the  pelvis  into 
the  substance  of  the  kidney,  with  resulting  single  or 
multiple  abscess  formation.  In  addition  to  the 
symptoms  of  pyelitis  there  may  be  increased  dullness 
and  fullness  in  the  kidney  area,  and  deficient  kidney 
functioning  as  evidenced  by  the  phenolsulphonephtha- 
lein  test. 

Treatment. — Treatment  on  the  lines  suggested  for 
pyelitis  should  be  given  a  prolonged  trial  unless  the 
patient  is  losing  ground.  Nephrectomy  or  nephro- 
tomy and  drainage  may  be  required,  especially  in 
cases  of  mixed  infection. 


CHAPTER   XXI 

GONOCOCCAL  INFECTIONS   OF   THE   EYE 

The  eye  may  become  the  seat  of  gonococcal  inflam- 
mation either  by  the  gonococcus  gaining  access  to 
the  conjunctiva  from  without  or  by  the  organism  or 
its  toxins  reaching  the  eye  through  the  blood-stream 
during  the  course  of  a  general  infection. 

Historical. — The  former  mode  of  infection  accounts 
for  the  vast  majority  of  cases  of  gonococcal  ophthal- 
mia ;  but  this,  although  surmised  by  an  occasional 
writer,  was  not  generally  known  previous  to  the  work 
of  Ricord  in  the  middle  of  the  eighteenth  century. 
In  the  "  Edinburgh  Medical  and  Surgical  Journal  "  of 
1807  Benjamin  Gibson  makes  certain  suggestions  for 
the  prevention  of  the  disease  in  new-born  infants, 
which  show  a  wonderful  comprehension  of  the  sub- 
ject, and  which  if  they  could  have  been  carried  out 
Avould  have  saved  the  sight  of  innumerable  children 
during  the  past  century.  His  recommendations 
were  : — 

1.  The  leucorrhoea  of  the  mother  ought,  if  possible, 
to  be  cured  during  pregnancy. 

2.  AMien  this  has  not  been  done,  the  noxious  secre- 
tion ought  to  be  removed  from  the  vagina  during 
delivery. 

3.  The  infant's  eyes  ought  immediately  after  birth 
to  be  cleansed  with  a  fluid  which  either  removes  the 
noxious  matter  or  is  able  to  prevent  its  injurious 
effects. 

308 


INFECTIONS   OF   THE   EYE  309 

Harman,  in  quoting  the  above  authority  (in  the 
"  Lancet  "  of  May  24th,  1913),  points  out  that 
Gibson  emphasises  the  necessity  of  curing  the  mother 
as  the  most  important  step  in  prophylaxis. 

Piringer  in  1841  showed  that  gonococcal  ophthal- 
mia owed  its  inception  to  direct  transference  to  the 
eye  of  gonorrhoeal  pus,  and  this  view  was  accepted  as 
explaining  all  cases.  Fournier,  however,  in  1866, 
reported  a  case  of  metastatic  gonorrhoeal  conjunc- 
tivitis, and  in  the  year  1881,  two  years  after  the  dis- 
covery of  the  gonococcus,  Heab  described  a  case 
which  he  attributed  to  metastatic  infection  owing 
to  his  inability  to  find  the  organism  in  the  secretion. 

Etiology. — The  great  majority  of  cases  are  due 
to  accidental  contamination  of  the  conjunctiva  either 
from  sponges,  handkerchiefs,  towels,  bath  water,  or 
the  hands,  or  during  the  passage  of  the  child  through 
the  genital  tract  of  the  mother  ;  but,  as  already  men- 
tioned, metastasis  accounts  for  a  small  proportion 
of  the  cases  of  gonococcal  eye  disease. 

The  most  important  group  of  gonococcal  eye 
inflammations  both  numerically  and  ophthalmologi- 
cally  is  that  included  under  the  term  "  Ophthalmia 
Neonatorum."  As  the  conjunctivitis  of  infants  differs 
in  some  material  respects  from  the  disease  as  seen  in 
adults,  it  warrants  a  separate  description. 

Ophthalmia  neonatorum  is  in  at  least  70  per  cent 
of  cases  due  to  the  gonococcus.  That  the  gonococcus 
has  not  been  found  in  this  percentage  of  cases  by  all 
observers  is  due  to  faulty  technique.  The  other 
organisms  which  have  been  found  in  the  conjunctivitis 
of  infants  are  the  pneumococcus,  bacillus  coli.  Weeks' 
bacillus,  streptococcus,  staphylococcus,  etc.  Two  or 
more  of  these  organisms  may  be  present  simul- 
taneously. 


310    GONORRHCEA  &  ITS  COMPLICATIONS 

Gonococcal  infection  of  the  eye  may  take  place 
in  utero,  owing  either  to  premature  rupture  of  the 
membranes  or  to  penetration  of  the  gonococcus  into 
the  amniotic  fluid.  In  these  cases  the  child  is  born 
with  a  well-developed  ophthalmia,  or  the  eyes  may 
even  be  totally  destroyed,  such  is  the  virulence  of  the 
disease  in  utero.  The  acute  course  which  characterises 
the  infection  in  utero  is  probably  due  to  the  even 
temperature  maintained  in  the  conjunctival  sac,  to 
the  want  of  drainage  if  the  lids  remained  closed, 
and,  if  opened  by  the  accumulation  of  pus,  to  the 
entrance  of  the  amniotic  fluid,  which  is  a  suitable 
culture  medium  for  the  gonococcus.  Quellmatz 
(1750)  was  the  first  to  note  the  occurrence  of  intra- 
uterine ophthalmia.  Guthrie  (1829),  Demours,  and 
Hasse  were  among  the  earliest  observers  of  this  con- 
dition. Sydney  Stephenson  (1907)  collected  ninety 
cases  from  literature  as  well  as  from  his  own  experi- 
ence. In  a  few  of  the  cases  the  children  were  born 
"  with  a  caul,"  thus  proving  either  the  placental 
transmission  of  the  gonococcus  or  the  penetration  of 
the  intact  membrane  by  gonococci  from  an  infected 
cervix.  The  latter  is  almost  certainly  the  true  ex- 
planation of  these  cases.  When  infection  takes  place 
in  the  parturient  canal,  the  most  dangerous  moment 
is  while  the  eyes  are  passing  over  the  taut  perineum^ 
as  the  lids  at  this  moment  are  most  liable  to  become 
separated. 

Inoculation  of  the  eye,  however,  is  much  more 
liable  to  take  place  during  the  cleansing  immediately 
following  birth.  Gonococcal  pus  derived  from  the 
cervix  and  adhering  to  the  skin  in  the  neighbourhood 
of  the  eyes  may  easily  be  washed  into  the  eye  by  the 
nurse  or  rubbed  in  by  the  hands  of  the  infant.  The 
bath  water  is  necessarily  contaminated,  and  unless 


INFECTIONS   OF   THE   EYE  311 

the  water  is  sufficiently  hot  to  destroy  the  gono- 
coccus  (112°  F.  or  over)  it  may  prove  the  means  of 
infection. 

Incidence. — Since  ophthahiiia  neonatorum  has  now 
been   made   a   notifiable   disease   in   many  towns   of 
America   and   Britain,   it   is   possible   to   form   some 
estimate  of  the  prevalence  of  this  condition.    Doubt- 
less many  cases  occur  which  are  not  reported  to  the 
Health  Officer.     Thus  in  Boston,  U.S.A.,  Avhile  the 
disease  was  listed  as  notifiable  and  every  effort  short  of 
prosecution  was  tried  to  obtain  the  notification  of 
cases,  it  was  known  that  the  law  was  disregarded,  an 
average  of  only  10  cases  per  month  being  certified. 
A  test  prosecution  raised  the  number  to  20  during 
that  particular  month,  but  during  the  following  month 
the  number  lapsed  again  to   10.     A  series  of  fresh 
summonses  caused  a  consecutive  rise  during  the  first 
four  months  of  1911  to  15,  32,  97,  and  116  respec- 
tively.    The   last   number   proved   thereafter   to   be 
about  the  monthly  average  for  that  city,  there  being 
in   1911   1068   cases  of   ophthalmia   neonatorum   re- 
ported.   London  adopted  notification  in  March,  1911, 
and  the  report  for  the  year  1911  (published  February, 
1913)  states  that  673  cases  were  notified  in  9i  months, 
which  would  give  850  cases  per  annum.    The  number 
of  births  (less  still-births)  during  the  same  year  was 
100,830.     This  gives  an  incidence  of  0-843  per  cent, 
which  is  undoubtedly  considerably  below  the  correct 
figure.     The  experience  of  the  Health  Authorities  in 
Glasgow  is   given   in   a  report   published   February, 
1913,  which  covers  a  period  of  17  months'  working  of 
the  system  of  notification.     In  that  time  341  cases 
were  reported,  which  represents  0-94  per  cent  of  the 
live  births. 

Gonococcal  ophthalmia  is  responsible  for  the  im- 


312    GONORRHCEA  &  ITS  COMPLICATION^ 

pairment  or  loss  of  vision  in  one-third  of  the  children 
in  asylums  and  schools  for  the  blind. 

The  incubation  ^period  is  short.     Evidence  of  the 
disease  is   as   a  rule  well  established   in    48    hours. 
The    prevalence    and    the    serious    import    of    this 
disease  has  now  aroused  the  attention  of  the  medical 
profession,  and  both  doctors  and  nurses  are  taught 
to  look  for  the  development  of  symptoms  suggestive 
of  its  onset,  in  every  puerperium  for  the  conduct  of 
which  they  are  responsible.      It   is   now  recognised 
that  draughts,  colds,  etc.,  are  not  the  cause  of  ophthal- 
mia of  the  new-born,  although  they  may  be  factors 
in    the    onset    of    some    of   the    25    to    30   per   cent 
of  cases  not  due  to  the  gonococcus.     In  the  present 
state  of  our  knowledge  the  attendant  who  belittles 
or  neglects  a  beginning  inflammation  of  an  infant's 
eye   is  incurring  responsibility   of  the  gravest  sort. 
Therefore    the    "  period    of    incubation  "    should   be 
reduced  to  its  narrowest  limits,  the  earliest  stage  of 
inflammatory  reaction  noticed,  the  organism  at  once 
searched  for,  and  treatment  begun. 

When  invasion  of  the  conjunctival  sac  has  taken 
place  in  the  uterine  cavity,  the  disease,  as  has  already 
been  mentioned,  may  be  well  established  at  the  date 
of  birth  and  noticed  at  the  first  inspection  of  the 
child.  When  infection  has  occurred  during  parturi- 
tion, symptoms  may  supervene  within  the  first  or 
second  day  after  birth  and  almost  certainly  within 
three  days.  Inflainmation  starting  after  the  third 
day  is  probably  due  to  the  infection  reaching  the  eye 
subsequent  to  birth  (secondary  infection).  But  any 
given  incubation  period  will  vary  with  the  precision 
with  which  the  eyes  of  the  child  have  been  observed. 
The  disease  is  as  a  rule  well  established  on  the  third 
day,  and  gross  symptoms  are  present  thereafter. 


INFECTIONS    OF   THE   EYE  313 

The  scrutiny  of  the  eyes  must  not  be  relaxed  until 
after  the  disappearance  of  the  lochial  discharge,  as 
at  any  time  during  the  puerperium  the  infant  may 
become  infected  by  careless  or  unclean  procedure  on 
the  part  of  the  mother  or  nurse. 

Symptoms. — The  earliest  symptoms  are  those 
mainly  of  irritation,  viz.,  redness  of  the  conjunctiva 
and  an  excess  of  serous  secretion.  The  redness  in- 
creases and  spreads,  the  secretion  becomes  purulent 
and  glues  the  eyelids  together.  On  separating  the 
lids,  which  has  to  be  done  after  bathing  with  warm 
solution  and  with  the  greatest  gentleness,  pus  freely 
exudes.  The  eyelids  become  swollen  and  oedematous. 
In    untreated    cases    the    inflammation    proceeds    to 


Fig.  72. 
All  rubber  goggles.     Illustration  supplied  by  Dunhills. 

ulceration  of  the  cornea  and  sloughing  with  resulting 
opacity  and  defective  vision  or  total  blindness,  and 
in  many  cases  with  destruction  of  the  eyeball. 

The  disease  may  start  in  one  eye  or  coincidently 
in  both  ;  but  it  is  seldom  that  the  condition  in  un- 
treated cases  is  confined  to  one  side  for  many  days. 

In  examining  a  child  in  whom  the  disease  is  well 
advanced,  the  infant's  head  should  be  placed  between 
the  aproned  knees  of  the  surgeon  while  the  body  is 
held  by  a  nurse.  Rubber  gloves  should  be  worn,  and 
it  is  a  useful  precaution  for  the  attendant's  eyes  to 
be  protected  by  goggles.  The  lids  are  bathed  in 
warm  solution  to  remove  crusted  secretion.  The 
utmost  delicacy  of  touch  must  be  exercised  in  over- 
coming the  spasm  of  the  orbicularis  so  as  to  avoid  the 


314    GONORRHCEA  &  ITS  COMPLICATIONS 

risk  of  pressure  on  the  eyeball  causing  perforation  of 
a  corneal  ulcer,  which  may  be  near  the  point  of  rup- 
ture. On  opening  the  eyelids  the  surgeon  must  be 
prepared  for  and  avoid  spurting  out  pus.  Before  the 
eye  can  be  examined  the  pus  must  be  carefully  re- 
moved by  washing. 

The  palpebral  conjunctiva  will  be  found  deeply 
congested,  especially  in  the  lower  fornix.  As  a  rule 
the  ocular  conjunctiva  is  affected  in  a  less  degree,  and 
chemosis  is  absent  in  infants,  probably  owing  to  the 
constant  closure  of  the  eyelids.  As  has  been  previ- 
ously indicated,  ulcers  may  be  found  on  the  cornea,  in 
which  case  a  most  guarded  prognosis  should  be  given. 

Diagnosis. — An  inflammation  of  the  infantile  con- 
junctiva of  increasing  severity  and  soon  associated 
with  the  formation  of  thick  creamy  pus  is  probably 
gonococcal ;  but  the  diagnosis  is  assured  by  finding 
the  causative  organism. 

The  manner  in  which  the  specimen  for  microscopical 
and  cultural  examination  is  prepared  is  of  the  greatest 
importance.  A  platinum  spoon  or  a  probe  wrapped 
round  with  sterile  cotton-wool  may  be  chosen.  In 
either  case,  the  palpebral  conjunctiva  of  the  everted 
lower  lid  is  curetted  or  wiped  gently  but  firmly  to 
obtain  its  adhering  secretion.  This  is  implanted  on 
sloped  tubes  of  serum  agar,  and  in  addition  it  is 
smeared  on  a  slide  for  immediate  staining  by  Gram's 
method.  Obtained  in  this  way,  the  specimen  will 
rarely  fail  to  show  the  gonococcus  if  it  is  present. 
The  intracellular  habit  of  the  organism  is  not  so  clearly 
shown  by  this  method  as  in  examining  a  drop  of  pus, 
but  many  typical  extracellular.  Gram-negative,  coffee- 
bean-shaped  diplococci  are  usually  located  without 
difficulty. 

Prognosis. — The  prognosis  depends  almost  entirely 


INFECTIONS   OF   THE   EYE  315 

on  the  stage  at  which  the  disease  comes  under  treat- 
ment. If  sloughing  ulcers  of  the  cornea  are  present 
the  outlook  as  regards  cure  without  impairment  of 
vision  is  bad.  In  children  wdth  the  additional  burden 
of  congenital  syphilis,  the  prognosis  is  grave  indeed. 
Prophylaxis. — Thanks  to  the  initiative  of  Crede, 
the  importance  of  prophylaxis  now  receives  a  certain 
proportion  of  the  recognition  to  which  it  is  entitled. 
But  full  value  will  only  be  got  from  prophylactic 
measures  when  each  supposedly  skilled  attendant 
recognises  his  or  her  personal  responsibility  for  the 
safety  of  the  child's  eyes,  and  understands  that 
practically  every  case  is  preventable. 

In  the  first  place,  it  should  be  part  of  an  obste- 
trician's routine  to  inspect  the  cervix  of  each  preg- 
nant patient  through  a  speculum,  and  if  pus  is  present 
to  have  it  bacteriologically  examined.  At  the  same 
time,  the  urethra  should  be  emptied  of  any  contents 
by  digital  pressure  from  above  downwards  through 
the  vagina,  and  if  any  pus  is  detected  a  urethral 
smear  should  be  examined.  This  procedure  would 
conserve  both  the  interests  of  the  child  and  the  mother 
by  enabling  treatment  appropriate  to  the  particular 
organism  to  be  initiated,  and  many  cases  of  puerperal 
fever  as  well  as  of  ophthalmia  would  be  prevented. 

Short  of  inspection  of  the  cervix,  the  practitioner 
should  at  least  assure  himself  by  cross-examination 
at  the  time  when  he  is  engaged  of  the  absence  of 
vaginal  discharge.  If  he  elicits  any  ground  for 
suspicion,  the  necessity  for  further  information  should 
be  insisted  on. 

The  treatment  required  for  gonorrhoea  in  pregnancy 
will  be  found  in  the  relative  chapter.  In  those  cases 
in  which  treatment  previous  to  the  onset  of  labour 
has  been  neglected  or  has  proved  ineffectual,  and  in 


816    GONORRHCEA  &  ITS  COMPLICATIONS 

which  a  purulent  discharge  is  still  present,  an  anti- 
septic vaginal  douche  should  be  given  during  the 
second  stage  of  labour,  as  is  the  rule  in  the  Rotunda 
Hospital,  Dublin. 

THE   TREATMENT   OF   OPHTHALMIA   NEONATORUM 

The  nature  of  the  prophylactic  treatment  which 
should  be  adopted  for  the  child's  eyes  depends  on 
whether  the  presence  of  parental  gonorrhoea  is  sus- 
pected or  not. 

1.  When  gonococcal  infection  of  the  mother  is  not 
suspected,  the  following  general  rules  apply  and 
should  be  adopted  at  every  birth  : — 

(a)  The  eyelids  and  eyelashes,  if  possible  before 
the  eyes  have  been  opened,  should  be 
thoroughly  wiped  free  of  all  adhering  mu- 
cus, etc.,  by  means  of  several  clean  pieces 
of  soft  linen  or  cotton-wool.  The  first  swabs 
may  with  advantage  be  moistened  with 
saline  solution  or  boric  lotion,  but  no 
solution  should  reach  the  inside  of  the  eyes, 
and  the  cleansing  should  be  completed  with 
dry  swabs. 
{b)  The  nose  and  mouth  should  next  receive  atten- 
tion, and  the  child's  hands  also  cleansed  lest 
in  rubbing  the  eyes  the  fists  should  re- 
implant  contagious  material, 
(c)  Clean  bath  water  should  be  used  for  the  head 
and  face  after  the  body  toilet  is  completed. 

The  universal  adoption  of  the  Crede's 
method  of  instilling  a  2  per  cent  silver  nitrate 
solution  into  the  eyes  has  been  frequently 
urged,  but  as  a  certain  amount  of  irritation 
follows  the  application  of  this  solution,  and 


INFECTIONS   OF   THE   EYE  317 

as  the  simple  procedure  described  above  is 
found  to  be  sufficient  except  in  very  occasional 
cases,  a  more  rigorous  routine  treatment  is 
undesirable. 

2.  A^Tien,  on  the  other  hand,  gonorrhoea  in  either 
of  the  parents  is  known  to  have  been  present,  or  is 
suspected  on  account  of  the  presence  of  purulent 
vaginal  or  urethral  discharge  or  the  history  of  eye 
trouble  in  a  former  birth,  an  additional  precautionary 
measure  is  essential,  viz.,  to  instil  into  each  eye 
some  antiseptic  which  can  be  expected  to  destroy  all 
the  gonococci  which  may  have  gained  entrance  into 
the  eyes.  The  ideal  antiseptic  would  be  one  which 
had  a  special  affinity  for  the  gonococcus,  and  could 
be  put  into  the  eye  in  an  active  gonococcicidal 
strength  without  damage  to  the  sensitive  infantile 
conjunctiva. 

Silver  nitrate  is  the  antiseptic  on  which  most  re- 
liance has  been  placed,  but  the  2  per  cent  solution 
suggested  by  Crede  is  now  generally  discarded  on 
account  of  its  too  irritating  properties,  and  when  the 
silver  nitrate  is  used  at  all  1  per  cent  is  the  strength 
recommended.  Stephenson  directs  that  one  drop  of 
1  per  cent  solution  should  be  placed  in  each  conjunc- 
tival sac  as  soon  as  possible  after  birth  of  the  head 
and  the  cleansing  of  the  eyeballs.  It  is  not  necessary 
to  evert  the  lids. 

In  preference  to  the  silver  nitrate,  many  authorities 
rely  on  one  of  the  organic  silver  preparations  on  the 
market.  Unfavourable  criticisms  of  these  proprietary 
articles  have  been  published  by  workers  who  felt  it 
necessary  to  refute  the  too  optimistic  advertising 
matter  scattered  broadcast  by  some  of  the  firms  own- 
ing the  compounds  ;  but  the  balance  of  opinion 
seems   to   support   the    value    of   the   organic   silver 


318    GONORRHCEA  &  ITS  COMPLICATIONS 

preparations  on  account  of  their  antiseptic  and 
penetrating  qualities  combined  with  the  minimum 
of  caustic  action  on  the  tissues. 

Darier  of  Paris  advocates  the  use  of  argyrol  as  a 
prophylactic.  After  thorough  external  cleansing, 
five  or  six  drops  of  a  10  to  15  per  cent  solution 
should  be  dropped  between  the  opened  lids  and  the 
margins  of  the  lids  brushed  with  the  fluid.  The 
solution  should  be  prepared  by  scattering  the  dry 
powder  on  cold  water  and  allowing  it  to  dissolve. 
A  drop  of  a  satisfactory  solution  run  over  a  glass  sur- 
face leaves  a  track  the  colour  of  tincture  of  iodine.  If 
the  smear,  on  the  other  hand,  is  watery  and  contains 
granules,  such  a  suspension  in  the  eye  would  ob- 
viously create  irritation.  Protargol  or  sophol,  5  per 
cent,  may  be  similarly  employed. 

Treatment. — The  main  essential  in  the  treatment 
of  ophthalmia  neonatorum  is  frequent  and  thorough 
flushing  of  the  conjunctival  sac.  No  pus  must  be 
allowed  to  accumulate  or  corneal  complications  with 
their  serious  effects  on  vision  are  almost  sure  to 
arise.  In  addition  to  washing  out  the  eye  every 
two  hours  or  more  frequently,  an  organic  silver  solu- 
tion should  be  instilled  every  four  hours. 

The  lotions  used  for  washing  the  eyes  are  sodium 
chloride  (1-4  per  cent)  ;  boric  acid  (saturated  solu- 
tion) ;  mercury  oxy cyanide  (1  in  4000)  ;  mercuric 
chloride  (1  in  8000)  ;  potassium  permanganate  (1  in 
3000).  Stephenson  recommends  that  previous  to 
douching,  the  eye  should  be  filled  with  hydrogen 
peroxide  (perhydrol,  Merck),  either  in  full  strength 
or  with  equal  parts  of  Avater.  The  pus  is  decomposed 
with  evolution  of  gas  and  wells  up  from  the  fornices, 
thus  promoting  its  easy  removal  by  the  solution, 
which  is  afterwards  allowed  to  flow  over  the  eye. 


INFECTIONS    OF   THE   EYE  319 

For  washing  out  the  eye  an  "  undme,"  i.e.,  a  glass 
flask  with  pointed  spout,  the  latter  protected  with  a 
short  length  of  soft  rubber  tubing,  is  the  handiest 
and  safest  appliance.  If  an  irrigator  is  used  the 
vessel  should  be  no  more  than  a  foot  above  the  level 
of  the  eye  and  the  flow  should  be  gentle  and  regular. 
Syringes  are  objectionable.  The  intervals  at  which 
the  eye  should  be  washed  out  depend  on  the  rapidity 
with  which  pus  forms,  but  in  a  case  which  is  well 
under  control,  every  two  hours  night  and  day  is  the 
usual  routine. 

As  a  gonococcicide,  silver  nitrate,  10  grains  to  the 
ounce  of  distilled  water,  has  been  largely  employed  ; 
but  to  obtain  the  full  benefit  of  this  application  the 
eyelids  must  be  everted  and  the  solution  painted  over 
the  exposed  conjunctiva.  When  simply  dropped  into 
the  eyes  the  effect  of  the  nitrate  is  limited  practically 
to  the  uncovered  area.  All  power  of  penetration  is 
inhibited  by  conversion  into  the  inert  chloride 
through  a  chemical  reaction  with  the  sodium  chloride 
of  the  tears  and  secretion.  To  evert  a  small  oede- 
matous  eyelid  is  often  a  difficult  and  painful  under- 
taking, and  in  any  case  is  properly  only  the  work 
of  the  medical  attendant  and  not  of  the  nurse,  and 
therefore  the  usefulness  of  the  silver  nitrate  is  limited. 

The  organic  silver  compounds  are  free  from  the 
difficulties  attached  to  the  use  of  the  inorganic  silver 
salts,  and  are  much  more  readily  diffused  over  the 
conjunctival  surface.  Argyrol  (25  per  cent),  protar- 
gol,  sophol,  etc.,  in  the  form  of  drops  may  be  em- 
ployed every  few  hours  after  all  pus  has  been  washed 
out.  In  cases  which  do  not  respond  to  argyrol, 
recourse  may  be  had  to  a  2  per  cent  silver  nitrate 
solution  applied  as  a  paint  by  the  surgeon. 

The   treatment    must    be   kept   up   until   all    pus 


320    GONORRHCEA  &  ITS  COMPLICATIONS 

formation  has  ceased,  and  until  gonococci  are  absent 
from  smears  prepared  according  to  the  method 
ah'eady  described.  Usually  about  six  weeks  of  this 
treatment  are  required. 

For  corneal  complications  a  few  drops  of  eserine 
sulphate  solution  (2  grains  to  the  ounce)  are  dropped 
into  the  eye  three  or  four  times  a  day  in  addition  to 
the  above  treatment,  and,  failing  speedy  improve- 
ment, the  affected  parts  may  require  to  be  cauterized 
by  means  of  the  galvano-cautery. 

If  only  one  eye  is  infected  the  sound  eye  should  be 
protected  with  a  cyanide  gauze  dressing,  but  it  must  be 
frequently  inspected  for  signs  of  beginning  disease. 

Gonococcal  conjunctivitis  in  the  adult  in  the  vast 
majority  of  cases  is  due  to  the  implantation  of  the 
organism  on  to  the  conjunctiva  through  the  medium 
of  the  hands,  handkerchiefs,  towels,  or  bath  water. 
Every  patient  with  urethritis  should  be  warned  of  the 
risk  of  conveying  infection  to  his  own  or  other 
people's  eyes. 

Gonococcal  conjunctivitis  is  marked  by  its  acuteness 
and  the  amount  of  pus  formation,  but  the  diagnosis 
depends  on  the  demonstration  of  the  gonococcus  in 
the  discharge.  The  symptoms  appear  in  from  one 
to  three  days  after  infection.  The  disease  is  usually 
limited  to  one  side  and  is  more  frequently  found  in 
the  male.  The  eyelids  are  hot,  swollen,  and  oede- 
matous.  The  discharge  is  at  first  thin,  serous,  and 
perhaps  blood-stained,  but  in  forty-eight  hours  it  is 
markedly  purulent.  Chemosis,  rare  in  the  infant,  is 
a  feature  of  the  disease  in  the  adult.  The  oedema  of 
the  conjunctiva  tends  to  produce  a  sulcus  round  the 
limbus  in  which  pus  collects,  and  the  digestive  action 
of  its  toxin  will,  if  allowed  to  continue,  quickly 
destroy  the  cornea.     The  necessity  for  the  constant 


INFECTIONS   OF   THE   EYE  321 

washing  away  of  the  pus  is  thus  even  more  urgent 
than  in  the  child. 

Hosford  and  James  ("  Lancet,"  January  13th, 
1913)  recommend  continuous  irrigation  with  a  solu- 
tion of  permanganate  of  potash  (1  in  20,000).  The 
douche  is  placed  one  foot  above  the  level  of  the  re- 
cumbent patient ;  a  fine  rubber  tube  is  strapped 
above  the  inner  canthus  of  the  eye  in  such  a  manner 
that  a  gentle  continuous  stream  will  flow  along  the 
palpebral  fissure.  The  patient  should  open  his  eye 
every  ten  minutes.  The  sound  eye  is  protected  with 
a  Buller's  shield.  Eight  days  of  this  treatment  is  said 
to  control  the  most  severe  cases.  The  patient,  of 
course,  lies  on  the  infected  side.  The  main  dis- 
advantages of  this  otherwise  admirable  method  is  the 
interference  with  the  patient's  sleep,  but  the  authors 
say  that  a  few  hours  at  a  time  is  usually  obtained, 
and,  if  necessary,  hypnotics  can  be  administered. 

In  the  absence  of  continuous  irrigation,  hourly 
rinsing  is  necessary,  and  four-hourly  instillation  of 
silver  as  described  for  ophthalmia  neonatorum. 

Corneal  complications  are  more  severe,  and  more 
frequent  in  adults  than  in  children.  They  may  occur 
early  or  late  in  the  disease.  When  there  is  much 
chemosis,  the  early  and  dangerous  form  of  ulceration 
may  be  anticipated.  The  first  symptoms  of  involve- 
ment of  the  cornea  is  the  appearance  of  a  dull  grey 
spot  either  in  the  interpalpebral  or  the  central  zone 
of  the  cornea.  This  area  usually  develops  into  an 
ulcer  which  may  be  either  clean  looking  or  yellowish. 
In  the  latter  case  it  is  likely  to  penetrate  the  cornea 
with  the  result  that  a  staphylloma  is  produced. 
Ulcers  forming  later  in  the  disease  may  be  central  or 
peripheral,  but  they  are  more  amenable  to  treatment 
than  the  earlier  forms. 

WATSON. — Y 


322    GONORRHCEA  &  ITS  COMPLICATIONS 

Atropine  (2  grains  to  the  ounce)  or  eserine  is  a 
necessary  addition  to  the  treatment  when  the  cornea 
becomes  imphcated,  and  the  galvano-cautery  may 
be  required  for  sloughing  ulcers. 

Arthritis  or  any  of  the  other  evidences  of  infection 
of  the  blood  may  arise  during  the  course  of  gonor- 
rhoeal  conjunctivitis. 

The  use  of  heat  as  a  gonococcicide  in  gonococcal 
ophthalmia.^The  fact  that  some  strains  of  gonococci 
are  destroyed  by  exposure  for  ten  minutes  to  a 
temperature  of  44°  C.  (111°  F.)  and  immediately  at 
45°  C.  (113°  F.)  suggests  the  possibility  of  using  heat 
as  a  method  of  treatment. 

Goldzieher,  of  Budapest,  has  reported  excellent 
results  in  a  series  of  cases  ("  Wiener  Klinische  Wochen- 
schrift,"  1911,  N.  47).  He  devised  a  portable  instru- 
ment by  means  of  which  a  jet  of  steam  can  be  directed 
against  the  conjunctiva  of  the  everted  lids  and  also 
the  ocular  conjunctiva.  This  instrument  is  electri- 
cally heated  by  connecting  with  a  wall  plug  and 
easily  handled  so  that  the  distance  of  the  spout 
from  the  eye  can  be  altered  as  desired.^ 

It  has  been  found  by  experiment  that  the  steam 
jet  from  this  kettle  when  allowed  to  play  on  a  sheet 
of  paper  (representing  the  conjunctiva)  produces  at 
the  distances  given  the  following  temperatures  : — 

C. 


Close  to  the  spout 

. 

80 

At  a  distance  of  0-5  cm. 

fr 

om  the  spout 

66 

1 

64 

1-5    „ 

60 

2 

56 

2-5    „ 

54 

3 

52 

4 

45 

*  This  apparatus  is  made  by  D.  Szikla,  Rakoezyut  19^  Budapest. 


INFECTIONS   OF   THE   EYE  323 

The  spout  is  therefore  held  3  to  4  centimetres  distance 
from  the  eye,  but  it  can  be  brought  as  near  as  2-5 
centimetres. 

The  use  of  moist  heat  is  much  less  likely  to  be 
followed  by  injury  than  would  dry  heat.  There  is, 
however,  considerable  pain  experienced,  especially 
with  the  first  application,  and  the  pain  is  not  ob- 
viated by  the  use  of  cocaine.  Gonococci  are  absent 
after  three  or  four  daily  applications,  and  the  remain- 
ing congestion  is  sufficiently  treated  with  0-5  per  cent 
zinc  sulphate  solution.  Further  reports  of  the  heat 
treatment  by  this  or  other  methods  will  be  awaited 
with  much  interest,  as  the  treatment  is  based  on  a 
rational  and  scientific  foundation. 

Metastatic  gonococcal  eye  disease. — Iritis  or  irido- 
cyclitis may  appear  as  a  feature  of  a  systemic  gono- 
coccal infection.  It  shows  a  tendency  to  recur  with 
each  fresh  attack  or  relapse  of  urethritis.  It  is  usually 
mild,  in  which  case  it  is  frequently  overlooked,  or  it 
may  be  severe  and  compel  attention.  The  pupil 
should  be  examined  with  reference  to  its  mobility  in 
all  cases  of  gonorrhoeal  rheumatism,  and  if  any 
degree  of  iritis  is  discovered  full  dilatation  should  be 
secured  and  maintained  by  the  use  of  atropine.  Apart 
from  the  local  use  of  atropine,  the  treatment  con- 
sists of  treating  the  urethritis. 

Metastatic  conjunctivitis,  apart  from  the  slight 
conjunctival  involvement  which  may  accompany 
iritis,  is  a  rare  condition,  but  several  cases  have  been 
reported  which,  from  their  mild  clinical  course, 
scarcity  of  gonococci  in  the  secretion,  and  the  presence 
of  a  concurrent  arthritis,  have  been  diagnosed  as  being 
of  metastatic  origin.  There  is  always  the  possibility 
of  error  in  concluding  that  a  conjunctivitis  is  of  endo- 
genous  origin   (really   a   sub-conjunctivitis),    as   the 


324    GONORRHCEA  &  ITS  COMPLICATION'S 

blood  infection  which  must  be  present  in  these  cases 
may  be  accompanied  by  the  formation  of  antibodies 
in  such  quantities  as  to  inhibit  the  activity  of  the 
organisms  which  have  reached  the  conjunctiva  from 
without,  and  thus  a  chnical  picture  may  be  produced 
which  is  indistinguishable  from  true  metastatic  con- 
junctivitis. The  diagnosis  depends  on  the  bilateral 
simultaneous  involvement  of  both  eyes,  the  slight 
amount  of  mucoid  discharge,  the  slight  swelling  of  the 
lids,  the  moderate  chemosis,  the  absence  of  gonococci 
in  the  discharge,  and  the  evidence  and  history  of 
a  systemic  infection. 

The  treatment  consists  of  active  treatment  of  the 
urethritis,  with,  locally,  argyrol  and  atropine. 

Gonococcal  choroiditis. — A  case  of  choroiditis  is  re- 
ported by  Vandegrift  ("  Journal  Amer.  Med.  Ass.," 
8.6.12).  "  The  clinical  picture  was  that  of  a  localised 
chorio-retinitis  attended  by  a  severe  hyalitis."  It 
was  associated  with  a  gonococcal  prostatitis,  and  was 
cured  by  a  mixed  gonococcus  and  staphylococcus 
vaccine  in  large  doses. 


CHAPTER   XXII 

GONORRHCEAL  RHEUMATISM 

Under  this  term  it  has  been  customary  to  include 
acute  and  chronic  inflammatory  conditions  due  to 
metastatic  implantation  of  the  gonococcus  in  the 
synovial  membrane  of  joints,  tendon-sheaths,  bursse, 
etc. 

Historical. — Various  early  writers  are  said  to  have 
noticed  the  association  of  rheumatism  with  gonor- 
rhoea. Certainly  the  conjunction  was  observed  by 
the  keen  eye  of  John  Hunter,  who  writes  in  1716  : 
"  I  know  one  gentleman  who  never  had  a  gonorrhoea 
but  that  he  was  immediately  seized  universally 
with  rheumatic  pains,  and  this  had  happened  several 
times."  According  to  Murrell  ("  Practitioner," 
January,  1912),  the  credit  of  being  the  first  to  es- 
tablish gonorrhoea!  rheumatism  as  a  definite  disease 
belongs  to  Sir  Benjamin  Brodie,  who,  in  his  "  Patho- 
logical and  Surgical  Observations  on  Diseases  of  the 
Joints  "  (1818),  gives  a  detailed  description  of  five 
authentic  cases. 

Incidence. — Different  observers  have  estimated  that 
rheumatism  occurs  in  from  2  to  10  per  cent 
of  cases  of  gonococcal  infection.  It  is  difficult  to 
arrive  at  anything  approaching  an  accurate  con- 
clusion on  this  point,  mainly  because  so  many  cases 
of  gonorrhoeal  rheumatism  escape  recognition  as  such, 
owing  to  the  suppression  of,  or  in  females  the  want 

325 


326    GONORRHCEA  &  ITS  COMPLICATIONS 

of  knowledge  of,  a  history  of  gonococcal  infection. 
Even  where  the  suspicion  arises,  that  in  a  given  case 
the  gonococcus  may  be  the  primary  cause  of  the 
condition  owing  perhaps  to  the  want  of  response  to 
salicylate  treatment,  the  diagnosis  may  remain  in 
doubt  in  the  absence  of  gross  urethral  discharge.  But, 
as  will  be  shown,  careful  analysis  of  the  symptoms 
and  history,  and  a  properly  guided  search  for  the 
gonococcus  will  clear  up  the  real  nature  of  many 
obscure  cases  of  rheumatic  complaints.  The  incidence 
of  rheumatism  as  experienced  in  any  class  of  well- 
treated  patients  such  as  soldiers  (1-7  per  cent.  Pollock 
and  Harrison),  shows  what  it  may  and  ought  to  be 
reduced  to,  but  gives  no  suggestion  of  the  ordinary 
prevalence  of  this  complication.  It  is  usually  main- 
tained that  males  are  much  more  liable  than  females. 
While  admitting  a  somewhat  greater  incidence  and 
a  decidedly  greater  morbidity  in  males,  it  must 
be  recognised  that  the  disease  is  frequent  in  females, 
and  many  cases  of  chronic  rheumatism  in  women  are 
due,  as  is  the  case  in  men,  to  an  uncured  focus  of 
infection  in  the  urogenital  tract.  In  young  girls,  the 
tendency  to  rheumatism  is  more  pronounced  than 
in  adult  females  ;  it  may  follow  either  vulvo-vaginitis 
or  ophthalmia  neonatorum.  Previous  attacks  confer 
no  degree  of  immunity,  but  on  the  contrary,  the 
patient  is  extremely  susceptible  to  a  recurrence  of 
the  joint  affection  with  any  relapse  of  the  urethritis 
or  on  reinfection.  One  or  several  joints  may  be 
affected.  In  order  of  relative  frequency  the  joints 
involved  are  the  knee,  ankle,  wrist,  fingers  and  great 
toes,  elbow,  shoulder,  hip,  temporo-maxillary.  Some 
joints  which  escape  in  ordinary  acute  rheumatism 
may  be  invaded  by  the  gonococcus,  e.g.,  the  sterno- 
clavicular,   costo-sternal,    sacro-iliac,    intervertebral. 


GONORRHGEAL   RHEUMATISM        327 

temporo-maxillary,  and  tarsal  articulations.  Teno- 
synovitis and  periarticular  tenderness  are  common 
and  should  excite  suspicion  as  to  the  nature  of  the 
case. 

Predisposing  causes. — Metastasis  is  prone  to  occur 
at  any  time  after  the  extension  of  a  urethritis  to  the 
posterior  urethra,  and  the  joints  most  likely  the  first 
to  be  involved  are  those  that  are  most  liable  to  suffer 
from  injury,  strain,  or  fatigue.  A  chill  during  the 
course  of  a  urethritis  may  determine  the  onset  of  a 
rheumatic  attack.  Digglemann  has  noted  the  ten- 
dency of  the  gonococcus  to  attack  joints  which  have 
been  affected  in  an  antecedent  acute  rheumatic  fever. 

Pathology. — The  gonococcus  reaches  the  synovial 
membrane  by  the  blood-stream.  It  becomes  located 
in  the  endothelium  and  subendothelial  tissues,  and 
there  sets  up  an  inflammatory  reaction.  Round- 
celled  infiltration  of  the  tissues,  oedema,  and  sero- 
fibrinous effusion  follow.  Later,  adhesions  are  pro- 
duced which  limit  the  movements  of  the  parts.  The 
gonococcus  can  be  recovered  from  the  effused  fluid 
and  from  scrapings  of  the  synovial  membrane.  It  is 
advisable  to  procure  if  possible  several  cubic  centi- 
metres of  the  fluid  for  plating  purposes,  as  the 
organism  is  usually  but  sparsely  distributed  in  the 
effusion.  On  one  occasion,  1  centimetre,  all  the  fluid 
obtainable  from  a  tender  knee  joint,  showed  only  one 
colony  after  forty-eight  hours'  incubation  (Martin). 

The  inflammatory  process  may  proceed  to  the 
formation  of  sero-pus ;  secondary  infection  by  a 
staphylococcus,  streptococcus,  or  bacillus  may  super- 
vene, in  which  case  erosion  of  the  cartilage  and 
destruction  of  the  joint  may  be  expected  unless  the 
joint  is  opened  and  free  drainage  maintained. 

Onset. — Metastatic    symptoms    may   arise   at    any 


328    GONORRHCEA  &  ITS  COMPLICATIONS 

time  during  an  acute  or  chronic  gonococcal  infection. 
So  long  as  there  is  a  site  in  which  the  gonococcus  sur- 
vives there  is  the  ever-present  danger  of  blood 
invasion  either  direct  or  through  the  lymphatic 
system.  Arthritic  symptoms,  however,  most  com- 
monly appear  in  the  third  week  of  an  acute  infection, 
i.e.,  when  the  disease  has  reached  the  posterior 
urethra,  but  they  have  appeared  as  early  as  the  fifth 
day  and  as  late  as  the  seventh  year  after  infection. 

Classification. — Osier  remarks  that  variability  and 
obstinacy  are  the  most  distinguishing  features  of 
gonorrhoeal  rheumatism,  and  he  describes  as  the  most 
important  of  the  possible  variations  the  following 
clinical  forms  : — 

1.  Arthralgic,  in  which  there  are  wandering  joint 

pains  with  redness  or  swelling. 

2.  Poly  arthritic,  with  involvement  of  several  joints, 

as  in  subacute  rheumatism. 
8.  Acute  gonorrhoeal  arthritis,   in  which  a  single 
articulation  becomes  suddenly  involved. 

4.  Chronic   hydrarthrosis,    usually    mono -articular 

and  particularly  liable  to  involve  the  knee. 
It  comes  on  often  without  pain,  redness,  or 
swelling. 

5.  Bursal  or  synovial  form.     Attacks  the  tendons 

and  their  sheaths,  bursse  (e.g.,  of  the  patella, 
the  olecranon,  or  the  tendo-Achilles),  and 
periosteum.  The  articulations  may  not  be 
affected. 

6.  Septicaemia,  in  which  the  patient  is  acutely  ill 

with  symptoms  of  an  intense  septico-pysemia 

usually  with  endocarditis. 
Keyes  accepts  two  main  divisions  : — 
(a)  Gonorrhoeal  arthritis,   in  which  the  organisms 

are  located  in  the  joint  itself. 


GONORRH(EAL   RHEUMATISM         329 

(b)  Gonorrhoeal  osteo-arthritis,  in  which  the  gono- 
cocci  are  localised  in  the  articular  extremities 
of  the  bones,  and  any  effusion  into  the  joints 
is  secondary.    The  cartilages  in  this  type  are 
liable  to  become  eroded,  and  bony  anchylosis 
may  result  or  spurs  may  be  formed  by  peri- 
osteal proliferation. 
These  two  conditions  may  be  differentiated  by  the 
appearances  shown  in  a  radiograph  ;    where  osteo- 
arthritis is  present,  bone  rarefication  is  always  mani- 
fest within  a  week. 

Symptoms. — In  the  acute  type  the  onset  is  sudden, 
with  a  rise  of  temperature  to  100°  or  even  103°  F., 
pain  and  swelling  of  any  joint,  but  most  commonly 
the  knee,  spreading  in  a  day  or  two  to  one  or  two 
other  joints  (rarely  three  or  four).  There  is  at  first 
but  little  redness  over  the  joints,  sweating  is  not 
noticeable,  and  pain  is  not  extreme  except  on  move- 
ment. There  is,  however,  marked  tenderness  on 
pressure,  some  thickening  of  the  synovial  membrane, 
and  some  effusion  into  and  around  the  joints.  During 
the  height  of  an  acute  attack  the  urethral  discharge 
may  disappear. 

Under  appropriate  treatment  this  condition  may 
quickly  resolve  and  leave  no  permanent  ill-effects. 
On  the  other  hand,  the  inflammatory  reaction  may 
become  intensified,  tendon  sheaths  and  bursas  be- 
come involved,  effusion  into  the  joint  and  periarticu- 
lar oedema  increase  with  the  appearance  of  purple 
areas  over  subcutaneous  tendons.  The  results  of 
the  latter  condition  are  too  frequently  permanent 
adhesions  and  immobility  of  the  affected  joint  with 
atrophy  of  the  muscles  of  the  limb. 

In  the  chronic  type  the  symptoms  suggest  an  inter- 
mittent or  continued  blood  invasion  from  some  latent 


330    GONORRHOEA  &  ITS  COMPLICATIONS 

focus  of  infection,  commonly  the  vesiculae  si minales  or 
Fallopian  tubes.  Several  joints  are  affected  sooner  or 
later,  prominent  among  them  being  the  knee  with  a 
tender  spot  over  the  internal  lateral  ligament,  the 
tarsal  joints  with  painful  heels  and  tendency  to  flat 
foot,  the  wrist  and  its  overlying  tendons,  etc.  Even 
in  cases  of  chronic  monoarticular  hydrarthrosis,  a 
careful  inquiry  will  usually  elicit  a  history  of  transient 
pains  in  other  joints.  Sweating  and  "  clamminess  " 
is  frequently  complained  of,  and  these  patients  tend 
to  develop  more  or  less  neurasthenia.  If  there  is  no 
effusion  in  or  round  a  painful  joint  the  pain  may  be 
due  to  an  adhesion,  the  accidental  or  voluntary  sever- 
ance of  which  may  be  followed  by  permanent  relief. 

A  patient  may  be  completely  crippled  by  chronic 
gonococcal  arthritis  with  adhesions  and  ankylosis. 
He  may  suffer  from  an  associated  anaemia  and  de- 
bility with  progressive  loss  of  weight  and  strength 
until  life  becomes  a  burden. 

Severe  headache  suggests  meningeal  implication, 
or  it  may  be  due  to  beginning  eye  trouble.  Endo- 
carditis or  pericarditis  may  develop  at  any  moment 
during  a  gonococcal  systemic  infection  with  or  with- 
out joint  symptoms,  but  heart  complication  is  much 
less  common  in  this  disease  than  in  ordinary  acute 
rheumatism. 

Diagnosis. — Gonococcal  is  distinguished  from  other 
forms  of  rheumatism  by  certain  clinical  points  as 
well  as  by  the  discovery  of  the  causative  organism. 
In  addition  to  the  failure  of  the  case  to  respond  to 
salicylate  treatment,  the  small  number  of  joints 
affected,  and  the  implication  of  joints  that  usually 
escape  in  the  other  types  (e.g.,  the  sterno-clavicular, 
the  temporo-maxillary,  sacro-iliac,  chondro-sternal, 
etc.)  will  assist  the  diagnosis.    Again,  the  tendency  to 


GONORRHCEAL   RHEUMATISM         331 

periarticular  infiltration  and  tenderness  and  to  in- 
volvement of  the  tendon  sheaths  and  bursse,  as  well 
as  the  absence  of  profuse  sweating  and  of  diffuse  red- 
ness of  the  skin  over  the  affected  joints,  would  sug- 
gest the  necessity  for  investigating  the  condition  of 
the  uro-genital  tract.  In  the  male,  if  gross  pus  be 
absent  it  will  in  most  cases  be  sufficient  to  examine, 
by  the  separate  glass  method,  the  morning  urine  or 
at  least  urine  which  has  been  retained  in  the  bladder 
for  some  hours.  The  presence  of  pus  in  flakes  or 
threads  suspended  in  the  urine  will  prove  the  per- 
sistence of  a  resolving  or  chronic  urethritis,  and  a 
search  for  the  gonococcus  will  then  be  necessary.  An 
attempt  to  cultivate  the  gonococcus  or  to  find  it  by 
microscopic  examination  of  a  smear  must  in  such 
cases  be  preceded  by  massage  of  the  seminal  vesicles 
and  prostate  and  expression  of  their  secretion  along 
the  urethra  to  the  previously  cleansed  meatus.  Several 
smears  may  have  to  be  examined  and  several  culture 
tubes  seeded  before  success  is  obtained  in  the  most 
chronic  cases,  but  care  and  perseverance  will  usually 
be  rewarded. 

In  the  female,  the  urethra  and  cervix  must  both 
be  included  in  the  search  for  the  gonococcus.  After 
thorough  cleansing  of  the  cervix  and  vagina  the  tubes 
and  uterus  are  examined  by  bimanual  palpation,  and 
the  cervix  is  again  displayed  and  cleansed  with  dry 
sterile  swabs.  The  handling  of  the  parts  has  prob- 
ably expressed  some  material  from  the  upper  passages 
and  this  should  be  examined.  As  a  rule,  however, 
the  gonococcus  is  more  readily  got  from  the  cervical 
glands  by  rotating  a  wool-wrapped  probe  within  the 
OS  while  exerting  some  pressure  on  the  cervix.  The 
urethral  smear  may  be  positive  even  when  those 
obtained  elsewhere  are  negative.     Skene's  ducts,  the 


332    GONORRHCEA  &  ITS  COMPLICATIONS 

vulvo-vaginal,  and  other  glands  should  be  scrutinised, 
and  para-urethral  passages  looked  for. 

In  chronic  cases  where  difficulty  is  experienced  in 
demonstrating  the  gonococcus  which  there  is  good 
reason  to  suspect  is  still  somewhere  present,  a  diag- 
nostic injection  of  vaccine  may  be  used  twenty-four 
hours  before  the  preparation  of  the  smears. 

In  the  event  of  failure  to  isolate  the  organism  from 
the  uro-genital  tract  it  may  be  desired  to  test  the 
joint  effusion.  For  this  purpose,  under  strict  asepsis, 
the  joint  is  penetrated  by  the  needle  of  a  10-cubic 
centimetre  syringe,  and  as  much  fluid  as  can  be  ob- 
tained withdrawn.  This  is  plated  with  2  per  cent  agar 
melted  and  cooled  to  40°  C,  adding,  if  sufficient  fluid 
be  available,  one  volume  of  effusion  to  two  of  agar. 
In  the  event  of  no  colonies  appearing  within  forty- 
eight  hours,  failure  should  not  be  assumed,  as  growth 
may  be  delayed  for  several  days.  Another  method 
not  open  to  the  risk  of  destroying  the  gonococcus  by 
the  heated  agar  is  to  run  a  small  quantity  of  the  fluid 
over  a  series  of  plates  or  tubes  of  ascites  agar  ;  or 
growth  may  be  attempted  by  adding  the  joint  con- 
tents to  ascites  broth. 

Apart  from  the  discovery  of  the  gonococcus  there 
are  other  tests  which  will  assist  or  secure  a  correct 
diagnosis.  The  most  valuable  is  the  complement 
deviation  test,  which  is  always  positive  in  gonococcal 
rheumatism.  The  skin  reaction  is  also  helpful.  These 
points  are  fully  discussed  elsewhere. 

There  should  therefore  be  no  difficulty  in  ascer- 
taining definitely  in  any  doubtful  case  of  rheumatism 
whether  it  is  of  gonococcal  origin  or  not.  It  should 
not  be  forgotten  that  a  patient  may  suffer  from  two 
infections,  gonorrhoeal  urethritis  and  acute  rheu- 
matic fever. 


GONORRHCEAL   RHEUMATISM         333 

Prognosis. — The  prognosis,  if  treatment  is  sub- 
mitted to,  is  good  so  far  as  the  prevention  of  further 
damage  to  the  joints  is  concerned,  but  it  is  doubtful 
so  far  as  recovery  of  disabled  joints  is  concerned. 
However,  once  the  disease  has  been  stayed,  as  it  can 
be  by  appropriate  treatment,  it  may  be  possible  by 
the  freeing  of  adhesions,  massage,  hot  air,  etc.,  to 
restore  a  joint  to  usefulness  which  when  first  seen 
looked  hopeless.  An  X-ray  photograph  may  indi- 
cate what  possibility  of  ultimate  cure  remains. 

Treatvient. — Apart  from  the  immediate  relief  of 
pain  and  apart  from  surgical  treatment,  the  main 
indication  is  by  suitable  means  applied  to  the 
primary  area  of  infection  to  prevent  further  con- 
tamination of  the  blood-stream.  It  is  in  gonococcal 
rheumatism  that  the  most  definite  and  satisfactory 
results  have  been  reported  from  the  use  of  gonococcus 
vaccines.  For  remarks  on  vaccine  therapy,  reference 
may  be  made  to  the  special  chapter  on  immunity 
reactions. 

In  acute  conditions  the  patient  will  require  treat- 
ment in  bed.  The  most  useful  agent  in  the  relief  of 
pain  is  immobilization  of  the  joint,  for  which  purpose 
moulded  splints  with  a  considerable  amount  of  cotton- 
wool to  ensure  the  exercise  of  a  gentle  elastic  pressure 
should  be  employed.  If  the  pain  is  not  sufficiently 
reduced  by  fixation  of  the  joint,  hot  fomentations 
may  prove  soothing,  or  the  application  of  equal  parts 
of  extract  of  belladonna  or  of  ichthyol  and  glycerine 
may  be  tried.  The  Bier  treatment  or  exposure  of  the 
joint  to  hot  air  are  each  of  service.  The  tendency  to 
the  formation  of  adhesions  must  be  kept  in  view,  and 
passive  motion  resorted  to  for  the  maintenance  of 
free  movement ;  but  too  early  or  too  forcible  passive 
movements  may  stimulate  into  activity  a  declining 


334    GONORRHCEA  &  ITS  COMPLICATIONS 

synovitis.  Massage  is  of  much  value  in  delaying  the 
muscular  atrophy  which  is  such  a  constant  feature  of 
prolonged  gonococcal  arthritis.  Counter-irritation  is 
valuable  both  in  reducing  the  inflammation  and 
allaying  pain,  and  the  most  effective  method  of  apply- 
ing it  is  by  light  scarification  with  the  galvano- 
cautery.  The  usual  anti-rheumatic  internal  remedies 
are  absolutely  useless  in  this  complaint,  and  restric- 
tions of  diet  also  have  not  the  same  significance. 
Deformities  and  loss  of  function  have  to  be  treated 
according  to  the  rules  of  orthopaedic  surgery. 

Queyrat  {vide  "  Lancet,"  October  12th,  1907), 
with  special  reference  to  cases  of  gonorrhceal  arthritis 
of  the  knee,  recommended  a  method  of  treatment 
which  he  maintained,  if  begun  early,  will  result  in 
cure  and  complete  restitution  of  function  within 
three  weeks.  His  principles  are  early  aspiration, 
energetic  counter-irritation,  and  early  movement. 
Aspiration  is  performed  on  the  outer  aspect  of  the 
knee  two  fingers'  breadth  behind  the  patella  with 
careful  aseptic  precautions.  He  performed  this  opera- 
tion over  200  times  without  untoward  result.  After 
the  paracentesis  of  the  joint  he  applies  the  point  of 
the  actual  cautery,  making  200  to  400  punctures  (200 
d  400  pointes  de  feu),  and  follows  this  by  methodical 
pressure.  Four  days  later  he  starts  progressive 
movements,  using  a  special  apparatus  with  a  weight- 
lifting  attachment. 

Felix-Ramond  ("  Bulletins  de  la  Soc.  Med.  des 
Hopitaux,"  November  10th,  1913)  reports  good 
results  from  auto-serotherapy  as  suggested  by  Gilbert, 
of  Geneva,  for  pleurisy  with  effusion.  From  3  to  5 
cubic  centimetres  of  the  arthritic  fluid  is  aspirated  into 
the  syringe.  The  needle  is  withdrawn  from  the  joint 
and  the  fluid  reinjected  subcutaneously.     He  states 


GONORRH(EAL   RHEUMATISM         335 

that  the  gonococcus  was  absent  from  the  effusion, 
but  this  is  open  to  question.  No  ill-effects,  however, 
resulted  in  his  six  cases  and  satisfactory  cures  were 
quickly  obtained.  When  the  effusion  was  purulent 
the  dose  was  reduced  to  1  cubic  centimetre  in  the  first 
treatment,  increasing  to  3  cubic  centimetres  in  the 
second.  Injections  were  repeated  every  two  or  three 
days  during  eight  to  ten  days.  This  treatment  has  a 
parallel  in  the  sensitized  vaccine  method. 

Intravenous  injections  of  colloid  silver  have  been 
favourably  reported  upon  by  some  German  surgeons. 

Fuller,  of  New  York,  maintains  that  in  a  large  pro- 
portion of  cases  of  gonorrhoeal  rheumatism  in  the 
male,  the  local  focus  from  which  systemic  infection  is 
maintained  and  which  is  responsible  for  the  per- 
sistence of  the  arthritic  symptoms  is  the  vesicula 
seminalis.  He  therefore  treats  these  cases  by  radical 
surgical  measures,  opening  the  diseased  sacs  and 
draining  them  through  a  perineal  wound.  In  this 
way  he  has  attained  remarkable  success  in  otherwise 
intractable  cases. 


CHAPTER   XXIII 

GONOCOCCUS   SEPTICEMIA 

That  the  gonococcus,  in  many  cases  of  gonorrhoea, 
finds  at  least  temporary  lodgment  in  the  blood- 
stream is  proved  by  the  occurrence  of  metastatic 
symptoms,  e.g.,  arthritis.  The  probability  is  that 
invasion  of  the  blood-stream  is  frequent,  but  that  only 
in  a  small  percentage  is  metastatic  deposition  of  the 
organism  in  the  various  susceptible  localities  accom- 
plished and  a  diseased  condition  produced.  In  a  still 
smaller  proportion  of  cases  does  the  presence  of  the 
gonococcus  in  the  circulating  blood  give  rise  to  symp- 
toms of  acute  septicaemia.  It  would  appear  that  the 
blood  of  the  average  individual  possesses  sufficient 
natural  resistance  to  the  gonococcus  to  prevent  its 
propagation  in  quantity  sufficient  to  produce  definite 
evidence  of  systemic  intoxication.  On  the  other 
hand,  cases  occur  which  prove  that  this  immunising 
power  may  occasionally  be  wanting,  and  in  such 
cases  serious  symptoms  arise  which  can  be  attributed 
to  the  blood  condition  alone,  apart  altogether  from 
the  absorption  of  toxins  from  areas  where  a  gonococcal 
inflammation  may  be  in  activity. 

This  condition  has  been  described  by  different 
writers  under  the  names  of  gonococcal  saprsemia, 
gonococcal  pyaemia,  gonopyaemia,  gonococcaemia,  and 
gonohaemia.  The  first  to  separate  the  gonococcus 
from  the  blood-stream  was  Hewes,  who,  in  1894,  suc- 

336 


GONOCOCCUS    SEPTICiEMIA  337 

ceeded  in  isolating  the  organism  from  blood  procured 
from  a  case  of  gonococcal  arthritis.  Lofaro  ("II 
Policlinico,  Sez.  Chirm-g.,"  Rome,  1911,  xviii,  49) 
discusses  the  literature  of  systemic  infection,  and 
gives  his  own  findings  in  sixty-seven  cases.  Lofaro's 
method  is  to  take  10  cubic  centimetres  of  blood  from  the 
median  basilic  or  other  suitable  vein,  mix  two  or  three 
drops  with  one  tube  of  ascitic  broth  and  5  to  8  cubic 
centimetres  with  another  similar  tube.  These  tubes 
are  incubated  at  37°  C.  for  forty-eight  hours,  when 
more  ascitic  fluid  is  added  and  the  contents  plated 
with  an  equal  quantity  of  ordinary  agar.  The  colonies 
are  counted  in  forty-eight  hours  and  smears  made  for 
microscopical  examination,  but  it  should  be  remem- 
bered that  colonies  may  appear  as  late  as  the  fifth  day 
of  incubation.  Of  the  sixty-seven  bloods  investigated, 
thirty-nine  gave  positive  results.  In  all  the  cases 
(eight)  of  acute  gonorrhoea,  meaning  within  thirty 
days  of  infection,  the  blood  was  sterile.  Of  twenty- 
six  cases  complicated  with  epididymitis,  colonies  of 
gonococci  were  obtained  in  nineteen.  Eleven  positive 
findings  were  obtained  out  of  nineteen  cases  of 
chronic  urethritis.  Lofaro  believes  that  the  gonococ- 
cus  reaches  the  circulating  blood  through  the  lym- 
phatic system,  and  this  is  probably  true  of  many 
cases ;  but  in  others  direct  entry  into  a  blood- 
vessel associated  perhaps  with  venous  thrombosis  is 
the  origin  of  the  systemic  infection. 

Classification  and  etiology. — The  expression  "  gono- 
coccus  septicaemia  "  is  here  used  to  indicate  those 
cases  in  which  the  blood  condition  dominates  the 
clinical  picture,  and  any  complication  such  as  joint 
or  heart  involvement  is  secondary  not  only  in  se- 
quence, but  in  significance.  The  gonococcus  gains 
the  circulating  blood  through  injury  or  disease  of  a 

WATSON. Z 


338    GONORRHCEA  &  ITS  COMPLICATIONS 

blood-vessel  wall  or  through  the  lymphatic  system. 
Owing  to  a  deficiency  in  the  protective  powers  of  the 
individual,  an  intoxication  is  produced  which  may 
either  run  a  short  acute  course  ending  in  recovery  or 
death,  or  become  chronic  with  a  liability  to  exacerba- 
tions. In  the  latter  case  the  condition  is  probably 
kept  up  by  a  series  of  reinfections  from  the  original 
source  of  supply. 

Several  rapidly  fatal  cases  have  been  reported  in 
which  neither  during  life  nor  post-mortem  were  there 
any  signs  of  metastatic  disease,  and  in  which  the 
diagnosis  depended  on  the  positive  results  of  the 
blood-cultures.  Many  obscure  cases  of  septic  intoxica- 
tion, resembling  typhoid  but  not  giving  its  character- 
istic reaction,  escape  recognition  of  their  true  etiology, 
owing  to  the  want  of  a  careful  and  thorough  bacterio- 
logical examination  of  the  blood.  The  gonococcus  will, 
of  course,  be  missed  unless  a  medium  suitable  for  its 
growth  is  chosen,  and  this  is  too  seldom  done  unless 
a  special  search  for  the  gonococcus  is  requested. 

Predisposing  factors. — Those  which  have  been  recog- 
nised are  traumatism  (especially  unskilful  instrumen- 
tation), alcoholic  and  venereal  excesses,  menstruation, 
pregnancy,  and  such  conditions  of  the  general  system 
as  lower  the  powers  of  resistance,  e.g.,  diabetes  and 
tuberculosis. 

Symptoms. — In  acute  gonococcal  septicaemia  the 
symptoms  are  characteristic  of  invasion  of  the  blood 
by  a  pathogenic  micro-organism.  Following  a  rigor, 
the  temperature  rises  to  103°  F.  or  more,  with 
irregular  fluctuations  thereafter.  The  temperature 
chart  may  be  similar  to  that  of  typhoid  fever  or  of 
a  pyaemia,  or  it  may  be  governed  by  no  regular 
periodism  whatever.  Malaise,  headache,  furred 
tongue,  thirst,  profuse  sweating,  anorexia,  vomiting, 


GONOCOCCUS    SEPTICAEMIA  339 

diarrhoea,  and  death  is  the  usual  sequence  in  the 
severest  cases.  The  disease  may  simulate  and  be 
mistaken  for  typoid,  malaria,  or  ulcerative  endocar- 
ditis. The  spleen  is  frequently  enlarged,  the  liver 
may  be  felt  below  the  costal  margin  or  it  may  be 
atrophic  with  symptoms  of  jaundice.  Albuminuria 
and  cutaneous  eruptions  or  petechise  are  not  un- 
common. 

In  chronic  pases  the  symptoms  are  less  severe  ; 
in  fact,  it  is  probable  that  many  mild  cases  are  over- 
looked entirely  or  mistaken  for  toxaemias.  It  is  not 
uncommon  to  get  a  history  of  continued  nightly 
rises  of  temperature  with  vague  feelings  of  uneasiness 
in  limbs  and  back,  sweating,  breathlessness,  and 
cardiac  weakness.  In  many  of  these  cases  it  is  diffi- 
cult to  say  whether  the  symptoms  are  due  to  absorp- 
tion of  toxins  from  a  local  lesion  or  to  a  partially  con- 
trolled septicaemia. 

Diagnosis. — The  diagnosis  is  wholly  dependent  on 
the  isolation  of  the  organism  from  the  patient's 
blood.  It  should  not  require  a  knowledge  of  the 
presence  of  a  concurrent  gonorrhoea  to  direct  attention 
to  the  possibility  of  the  gonococcus  being  the  offen- 
sive agent  in  an  obscure  septicaemia.  The  gonococcus 
being  one  of  the  most  common  disease  producers,  all 
blood  examinations  for  unknown  infecting  agents 
should  include  a  search  for  this  germ.  Examination 
of  the  genital  tract  will  usually  demonstrate  the 
existence  of  a  chronic  lesion  ;  the  method  of  examina- 
tion is  dealt  with  elsewhere  (see  gonococcal  arthritis, 
etc.). 

Complications. — The  most  frequent  complication  is 
arthritis,  and  the  most  important  is  endocarditis. 
Pericarditis,  meningitis,  peritonitis,  pneumonia, 
pleurisy,   iritis,   conjunctivitis,   thrombosis,   and  em- 


340    GONORRHGEA  &  ITS  COMPLICATIONS 

bolism  may  also  arise  and  add  to  the  difficulties  of 
treatment. 

Prognosis. — Apart  from  the  occurrence  of  complica- 
tions, the  outlook  largely  depends  on  the  acuteness  of 
the  septicaemia.  It  is  nearly  always  possible  to 
eradicate  the  local  focus  and  prevent  reinfection  if  the 
patient's  condition  is  such  as  to  justify  surgical 
intervention.  But  apart  from  any  reinfection,  the 
resisting  power  of  the  blood  in  some  cases  is  so  feeble 
that  the  disease  proves  fatal  either  rapidly  or  after 
a  more  or  less  protracted  struggle.  The  prognosis 
should  therefore  always  be  a  guarded  one  in  acute 
cases,  because  of  the  difficulty  of  stimulating  the 
formation  of  antibodies,  and  in  subacute  cases 
because  of  the  risk  of  serious  complications. 

Treatment. — Evacuation  and  free  drainage  of  any 
abscess  cavity,  however  small,  is  the  first  indication, 
provided  that  the  patient  is,  in  the  surgeon's  opinion, 
in  a  condition  to  stand  the  necessary  operation. 
Alcohol  is  contra-indicated  as  a  stimulant,  and  reli- 
ance in  this  respect  must  be  placed  on  strychnine 
and  a  sustaining  and  easily  assimilated  diet.  The 
temperature  may  be  controlled  by  cool  baths  or  packs. 
Vaccine  treatment  one  would  hesitate  to  employ  in 
acute  septicaemia  where  there  are  indications  of 
failure  of  the  blood  to  respond  to  the  call  on  its  im- 
munising mechanism,  and  where  any  increase  in  the 
already  pronounced  "  negative  phase  "  might  result 
in  total  collapse.  An  injection  of  15-25  cubic 
centimetres  of  anti  -  gonococcus  serum,  followed 
if  necessary  in  24  to  48  hours  by  a  second 
dose,  is  more  likely  to  be  helpful.  The  only  risk 
run  in  this  case  is  that  of  increasing  the  patient's 
discomfort  should  symptoms  of  serum  -  sickness 
supervene. 


GONOCOCCUS   SEPTICEMIA  341 

In  subacute  and  chronic  cases,  vaccines  are  said  to 
have  been  beneficial. 

The  colloid  silver  collargol  has  been  used  intra- 
venously in  doses  of  10  cubic  centimetres  of  a  1  or  2 
per  cent  solution  in  normal  saline  daily  for  three  or 
four  days  with  satisfactory  results  reported. 


CHAPTER   XXIV 

GONOCOCCAL   AFFECTIONS   OF   THE   HEART   AND 
BLOOD-VESSELS 

It  is  universally  believed  that  the  gonococcus  can 
flourish  in  the  blood  of  a  susceptible  individual,  the 
accepted  proof  being  the  separation  of  the  organism 
from  the  blood  of  a  patient  showing  symptoms  of 
acute  septicaemia.  One  would  expect  in  view  of  the 
characteristic  predilection  of  the  gonococcus  for  epi- 
thelial tissue  that  at  least  a  proportion  of  septicaemic 
cases  would  be  associated  with  involvement  of  the 
epithelial  lining  of  the  circulatory  system,  and  this  is 
in  accordance  with  the  clinical  and  pathological  find- 
ings. Endocarditis  with  more  or  less  myocarditis, 
pericarditis,  aortitis,  endarteritis,  and  phlebitis  due  to 
the  gonococcus  in  pure  culture  have  all  been  fre- 
quently demonstrated. 

Endocarditis. — Ricord  (1847)  noticed  the  conjunc- 
tion of  endocarditis  with  gonorrhoea,  and  this  asso- 
ciation was  specially  emphasised  by  Brandes  in  1854. 
Thayer  and  Blumer  (1895)  cultivated  the  gonococcus 
from  the  blood  of  a  patient  suffering  from  endocar- 
ditis. Over  two  hundred  indisputable  cases  have 
since  been  reported,  and  it  is  now  recognised  that  the 
condition  of  the  heart  must  be  watched  in  every  case 
of  posterior  urethritis. 

Pathology. — No  clinical  or  macroscopic  feature  of 
gonococcal  endocarditis  has  been  described  which 
would  differentiate  the  gonococcal  from  other  forms 


HEART   AND   BLOOD-VESSELS         343 

of  endocardial  inflammation.  Vegetations  composed 
of  fibrin  and  infiltrated  with  leucocytes  and  gono- 
cocci,  erosions  going  on  to  ulceration  and  valvular 
destruction,  and  thrombi  are  commonly  found. 

The  diagnosis  is  dependent  on  the  isolation  of  the 
causative  organism.  A  few  cases  in  which  strepto- 
cocci and  staphylococci  were  found  along  with  the 
gonococcus  have  been  reported. 

Symptoms. — In  the  majority  of  cases  the  symp- 
toms are  less  acute  than  in  ulcerative  endocarditis 
due  to  other  organisms.  The  temperature  rises  to 
101°  or  103°  F.  in  the  common  type.  Dyspnoea, 
precordial  pain,  and  palpitation  with  cardiac  dilata- 
tion and  displacement  of  the  apex  beat  along  Avith 
auscultatory  signs  of  a  heart  lesion  are  present  sooner 
or  later.  The  endocarditis  may  be  overshadowed  by 
the  septicaemia  or  by  arthritis,  in  which  case  it  would 
be  looked  on  as  a  complication  of  the  more  prominent 
condition.  Embolic  metastasis  may  involve  the 
spleen,  liver,  kidneys,  brain,  etc.,  but  a  resulting  gono- 
coccal abscess  in  these  situations  is  rarely  found.  The 
lesions  are  usually  confined  to  the  left  side  of  the  heart, 
and  embolism  in  the  lungs  is  therefore  very  uncom- 
mon. An  analysis  of  the  reported  cases  indicates  the 
relative  frequency  with  which  the  different  valves  are 
involved  to  be  as  follows  : — 

Mitral 48      % 

Aortic 39-7 ,, 

Pulmonary.  .  .  .  .        5-3,, 

Tricuspid    .  .  .  .  .        2-6 ,, 

Men  are  more  frequently  attacked  than  women,  and 
women  are  more  susceptible  during  pregnancy  or  the 
puerperium. 

The  etiology  and  treatment  have  been  discussed 
under  septicaemia. 


344    GONORRHCEA  &  ITS  COMPLICATIONS 

Pericarditis  is  evidenced  by  prsecordial  pain  and 
tenderness,  friction,  muffled  first  sound,  increased 
cardiac  dullness,  and  dyspnoea.  It  is  considerably 
less  frequent  than  endocarditis.  The  amount  of 
effusion  is  seldom  great,  but  on  a  rare  occasion  it  may 
require  to  be  aspirated  in  order  to  relieve  the  dyspnoea. 
The  point  of  puncture  is  to  the  left  of  the  base 
of  the  xiphoid  cartilage  (Marfan's  point).  The  fluid 
may  be  serous,  serofibrinous,  blood-stained,  or  puru- 
lent. 

Phlebitis. — The  pampiniform  plexus  of  the  sper- 
matic cord  or  of  the  broad  ligament,  and  the  prostatic 
plexus  of  veins  are  the  most  common  areas  to  be 
primarily  affected.  The  process  may  extend  es- 
pecially to  the  veins  of  the  lower  limb,  a  rare  result 
being  thrombosis  and  gangrene.  Several  mild  cases 
involving  the  external  saphenous  vein  and  ending 
in  complete  recovery  have  been  reported. 

Treatment. — In  addition  to  treatment  of  the  genital 
focus  and  of  the  septicaemia,  complete  rest  of  the 
affected  parts  should  be  secured  by  appropriate 
splints  and  bandages. 


CHAPTER   XXV 

GONOCOCCAL   SKIN   LESIONS 

Buschke  ("Arch.  f.  Derm.  u.  Syph.,"  1899,  voL 
xlviii,  p.  181)  classifies  the  cutaneous  eruptions 
associated  with  gonococcal  infection  into  four  divi- 
sions : — 

1.  Simple  erythema. — Care  has  to  be  exercised  to 

exclude  all  cases  which  might  be  balsamic  or 
syphilitic  in  origin  ;  but  after  due  allowance 
has  been  made  for  error  in  this  respect  there 
remains  a  sufficient  number  to  make  this 
the  most  frequent  form  of  gonococcal  erup- 
tion. In  this  group  are  included  the  small 
red  papules  which  occur  on  the  trunk,  arms, 
and  thighs,  and  the  typhoid-like  rose  spots 
which  are  sometimes  seen  in  the  septicsemic 
state.  The  erythema  of  the  external  genitals 
not  uncommonly  found  in  women  suffering 
from  gonorrhoeal  discharge  is  of  a  different 
nature,  being  due  to  external  irritation. 

2.  Urticaria  and  erythema  nodosum,  indistinguish- 

able from  the  ordinary  varieties,  occur  in 
some  cases.  There  are  usually  other  evi- 
dences of  a  general  infection,  e.g.,  arthritis. 

3.  Hcemorrhagic  and  bullous,   exanthems   sympto- 

matic of  severe  septicaemia  and  possibly  due 
to  embolism.  Gonococci  have  been  demon- 
strated in  some  cases  of  each  of  the  above 
three  varieties  of  skin  lesion. 

345 


346    GONORRHCEA  &  ITS  COMPLICATIONS 

4.  Hyperkeratosis. — This  group  includes  the  only 
variety  which  can  be  said  to  be  a  specific 
manifestation    of    gonococcal    infection.      It 
therefore  requires   more   detailed   considera- 
tion.     Various   names   have   been   suggested 
for  this  affection  with  more  or  less  reasonable- 
ness,  but  custom  has  meantime  established 
the  term  "  Keratodermia  blenorrhagica." 
Keratodermia  blenorrhagica  was  first  described  as 
a  specific  disease  by  Vidal  in  1893.     Since  that  date 
twenty-five  cases  or  more  have  been  reported.    Simp- 
son published  a  very  complete  article  on  the  subject 
in  the  "  Journal  of  the  American  Medical  Associa- 
tion," August  24th,  1912,  in  which  a  synopsis  of  the 
previously  reported  cases  is  given.     The   first   case 
reported   in   England   was   a   patient   of   Dr.   J.   H. 
Sequiera  (Sequiera  and  Turnball,   "  British  Journal 
Dermat.,"  1910,  vol.  xxii,  p.  139). 

Etiology. — Arthritis  was  a  feature  of  all  the  pub- 
lished cases  except  in  two  reported  by  Robert.  There 
is  thus  evidence  of  systemic  infection  by  the  gono- 
coccus,  but  so  far  the  organism  has  not  been  found  in 
the  skin  lesion.  The  etiological  relationship  of  the 
gonococcus  to  the  disease  is,  however,  proved  by  the 
presence  of  a  gonococcal  infection  in  every  case  prior 
to  the  appearance  of  the  skin  lesion,  and  by  the  fact 
that  the  cutaneous  appearances  conform  to  no  other 
known  type  of  skin  disease.  Cutaneous  scars,  e.g., 
vaccination  marks  and  the  skin  regions  most  exposed 
to  irritation  (hands  and  feet),  are  the  sites  most  liable 
to  be  attacked. 

Pathology. — Baermann  showed  that  the  horny 
growths  characteristic  of  the  disease  were  not  true 
keratoses,  but  resulted  from  a  parakeratosis,  and  he 
therefore  proposed  the  name.  "  dermatitis   papillaris 


GONOCOCCAL   SKIN   LESIONS         347 

parakeritotica."  The  essential  histological  feature  in 
addition  to  the  parakeratosis  is  a  leucocytic  infiltra- 
tion deep  and  epidermic,  composed  of  leucocytes  and 
sometimes  mast  cells. 

Macroscopic  appearance  of  the  lesions. — The  sites 
of  election  are  the  feet  and  hands,  but  the  eruption 
may  be  general  and  appear  on  the  limbs,  trunk,  and 
head.  The  lesion  in  its  initial  stage  is  usually  a  small 
papule  or  pustule  with  a  raised  horny  centre,  under 
which  is  a  drop  of  viscid  waxy  material  composed  of 
leucocytes  and  desintegrating  epithelium.  The  re- 
sulting "  scab  "  projects  as  a  horny  conical  growth, 
becoming  ultimately  not  unlike  a  rupial  crust  and 
increasing  in  size  centrifugally.  Sometimes  the  horny 
nodes  are  wax-like  and  translucent.  On  removing 
the  crust  a  moist  area  of  reddened  skin  is  left.  A 
diffuse  keratosis  of  the  palm  or  sole  is  frequently 
produced  with  nodes  at  irregular  intervals.  The 
nails  may  be  involved  and  ultimately  exfoliate.  The 
nodes  frequently  project  1  to  2  centimetres,  and  measure 
2  to  3  centimetres  in  diameter.  A  severe  balanitis  has 
been  a  feature  of  many  of  the  cases.  Destruction  or 
ulceration  of  the  skin  is  never  seen.  No  scarring 
therefore  is  found  when  healing  is  complete. 

Diagnosis. — Syphilis  must  be  negatived,  as  some- 
times the  lesions  simulate  a  seborrhoea-psoriasis 
syphilide.  The  largest  and  oldest  nodes  may  resemble 
rupia,  but  an  inflammatory  base  is  lacking. 

Prognosis.— The  skin  condition  will  completely 
clear  up  by  desquamation  and  exfoliation  if  and  when 
the  gonococcal  infection  is  cured. 

Treatment. — Most  observers  agree  that  local  treat- 
ment of  the  skin  is  of  little  or  no  value.  Indeed, 
those  parts  left  untreated  have  apparently  done  better 
than  areas  covered  with  ointments.     Simpson,  how- 


348    GONORRHCEA  &  ITS  COMPLICATIONS 

ever,  recommends  a  sulplmr  and  resorcin  ointment. 
The  gonococcal  infection  is  the  most  important  ele- 
ment requiring  treatment.  Urotropin  is  credited 
with  determining  a  rapid  cure  in  one  reported  case. 

Gonococcal  infections  of  skin  wounds  and  ulcers 
have  been  reported  in  a  few  cases.  Pustules  have 
been  produced  by  scratching  with  infected  finger-nails 
and  subcutaneous  abscesses  have  in  a  few  cases  been 
found  to  contain  the  gonococcus. 


CHAPTER   XXVI 

IMMUNITY  REACTIONS 

Immunity  reactions. — The  immunity  reactions  which 
can  be  excited  by  the  gonococcus  in  addition  to  their 
scientific  interest  have  an  important  practical  bearing 
on  certain  methods  of  diagnosis.  But,  above  all,  these 
reactions  require  full  consideration  in  any  attempt 
to  elucidate  the  intricacies  of  vaccine  treatment. 

The  failure  of  all  attempts  to  produce  gonococcal 
infection  in  animals  has  severely  handicapped  all 
efforts  to  study  the  questions  of  immunity  in  their 
special  relationship  to  the  gonococcus.  No  toxin 
seems  to  be  elaborated  by  the  gonococcus,  but  Wasser- 
mann  and  others  have  shown  that  there  are  certain 
endocellular  substances,  endotoxins,  which  when 
injected  into  man  and  animals  produce  toxic  symp- 
toms. Miiller  and  Oppenheim,  Bruck  and  also  Van- 
nod  (1906)  proved  that  a  real  immunity  reaction  does 
occur  in  man.  They  showed,  by  means  of  the  comple- 
ment deviation  test,  that  bodies  of  the  nature  of 
amboceptors  were  present  in  the  blood  of  patients 
suffering  from  general  gonococcal  infection.  Since 
then  a  considerable  amount  of  work  has  been  done 
on  the  complement  deviation  phenomenon,  on  agglu- 
tination and  opsonic  action,  the  presence  of  precipitins 
and  bactericidal  substances,  and  finally  on  skin  re- 
actions, all  of  which  substantiate  the  view  that  a 
specific  immunity  of  a  complex  constitution  is 
elaborated  against  the  gonococcus. 

349 


350    GONORRHOEA  &  ITS  COMPLICATIONS 

The  future  may  evolve  methods  by  which  agglutina- 
tion and  opsonic  action  will  be  in  general  use  as  effec- 
tive guides  to  the  progress  of  gonococcal  infection,  but 
meantime  only  a  few  workers  can  report  anything 
like  consistent  results  with  these  two  reactions. 

Agglutination. — Vannod  (1906),  Torrey  (1907), 
Elser  and  Huntoon  (1909)  maintain  that  the  three 
organisms  which  owing  to  morphological  similarity 
are  capable  of  being  confused  (gonococcus,  meningo- 
coccus, and  micrococcus  catarrhalis)  may  be  differen- 
tiated by  agglutination  tests,  provided  that  one  uses 
active  sera  and  that  one  avoids  strains  that  are 
highly  inagglutinable.  The  results  must  also  be 
properly  controlled,  and  it  should  be  remembered 
that  the  gonococcus  is  especially  susceptible  to  normal 
rabbit  and  group  agglutinins.  Some  strains  are 
apparently  inagglutinable  ;  others  show  spontaneous 
agglutination.  This  property  of  the  organisms  is 
also  influenced  by  the  culture  medium  on  which 
they  are  grown. 

Opsonic  action. — As  regards  opsonic  action  similar 
difficulties  are  met  with.  Some  strains  show  spon- 
taneous phagocytosis,  while  the  failure  of  phagocyto- 
sis in  others  introduces  a  considerable  element  of 
uncertainty.  Enough  has  been  said  to  indicate  that 
these  procedures  so  far  as  they  have  been  practised 
are  not  yet  on  a  sufficiently  firm  basis  to  be  of  practi- 
cal value  in  diagnosis  or  the  control  of  treatment. 

Precipitins. — Torrey  and  others  have  demonstrated 
that  specific  precipitins  are  present  in  the  serum  of 
immunised  animals.  There  is  no  apparent  relation- 
ship between  the  agglutinin  and  precipitin  contents 
of  the  serum. 

Bactericidal  action. — Martin  (1910)  emphasises  the 
difficulties  of  investigating  this  subject.     These  are 


IMMUNITY   REACTIONS  351 

mainly  due  to  the  tendency  of  the  gonococcus  to 
undergo  autolysis  in  salt  solution  and  to  its  tempera- 
ture sensitiveness.    His  conclusions  are  : — 

1.  Normal  sera  may  be  bactericidal  towards  gono- 

cocci.  Of  these  tested  (guinea-pig,  rabbit, 
cat,  human),  cat's  serum  has  proved  most 
active. 

2.  From  rabbits  inoculated  with  hving  cultures  of 

gonococci,  bacteriolytic  immune-bodies  have 
been  obtained  which  can  be  reactivated  by 
feebly  acting  normal  sera,  a  marked  bacteri- 
cidal action  resulting.    These  immune-bodies 
are  relatively   specific ;    thus   a  reactivated 
rabbit    v.    gonococcus    serum    which    has    a 
marked  bactericidal  effect  on  the  gonococcus 
has  only  a  shght  effect  on  the  meningococcus. 
Martin's  results  demonstrate  the  presence  of  specific 
bactericidal  immune-bodies  in  the  sera  of  immunised 
animals    which    can    be    activated    by    complement 
(present  in  normal  serum).    His  evidence  so  far  as  it 
goes  suggests  that  there  is  a  scientific  basis  for  treat- 
ment  aiming   at   an   increase   in   the   quantity   and 
efficiency  of  these  bodies,  but  whether  this  treatment 
should  be  by  active  immunity  (vaccines),  or  by  pas- 
sive (serum),  he  leaves  to  the  future. 

COMPLEMENT   DEVIATION 

As  previously  mentioned,  the  Bordet-Gengou  re- 
action, used  so  successfully  by  Wassermann  in  syphihs, 
has  been  applied  to  gonococcal  infection  by  Miiller 
and  Oppenheim,  as  well  as  several  other  workers  from 
1906  onwards,  but  it  is  to  Schwartz  and  McNeil,  who 
took  practical  advantage  of  the  important  investiga- 
tions of  Teague  and  Torrey,  that  the  credit  of  having 


352    GONORRHCEA  &  ITS  COMPLICATIONS 

made  this  test  of  clinical  value  is  due.  Their  pro- 
cedure and  the  results  obtained  in  324  cases  are 
described  in  the  "  American  Journal  of  Medical 
Sciences,"  May,  1911. 

The  reaction  depends  on  the  circumstances  that, 
in  the  presence  of  complement,  gonococcal  endotoxin 
(antigen)  combines  with  gonococcal  antibodies 
(patient's  serum),  and  that  in  doing  so  complement 
(guinea-pig's  serum)  becomes  "  fixed  "  or  "  deviated." 
That  complement  has  in  this  manner  been  deviated 
can  be  ocularly  demonstrated  by  the  addition  to  the 
tube  of  a  "  hsemolytic  system,"  the  red  blood  cor- 
puscles of  which  will  dissolve  only  if  free  complement 
is  present.  The  fixation  of  the  complement  which 
occurs  if  gonococcal  antibodies  are  contained  in  the 
patient's  serum  prevents  lysis  of  the  red  corpuscles, 
and  a  "  positive  "  reaction  is  then  said  to  have  been 
obtained.  The  following  reagents  are  therefore  re- 
quired : — 

1.  The  patienfs  serum. — This  is  obtained  by  punc- 

turing a  vein  with  a  salvarsan  needle.  About 
5  cubic  centimetres  of  blood  are  required  if  the 
original  Wassermann  quantities  are  employed 
in  the  laboratory,  but  if  one-tenth  doses  are 
adopted  1  cubic  centimetre  of  blood  is  sufficient. 
The  blood  is  collected  in  a  sterile  test  tube, 
allowed  to  clot,  and  the  serum  pipetted  off. 
This  serum  is  inactivated  by  heating  for 
thirty  minutes  at  57°  C.  This  temperature 
destroys  the  complement,  which  is  thermola- 
bile,  but  leaves  the  antibodies  unimpaired  as 
these  bodies  are  thermostabile. 

2.  The  gonococcal  antigen. — A  stock  antigen  is  pre- 

pared by  extracting  the  soluble  constituents 
of  as  many  individual  strains  of  gonococci  as 


IMMUNITY   REACTIONS  353 

are  known.    Teague  and  Torrey  showed  that 
different  strains  of  gonococci  refuse  to  react 
except  with  their  respective  antibodies,  and 
they    proved    that    there    are    at    least    ten 
different  strains  of  gonococci.     In  order  to 
obtain    constant    and    reUable    results    it    is 
therefore  essential  that  a  representative  of 
each  strain  should  be  included  in  the  mixed 
antigen.      The    admixture    of    ten    separate 
cultures  obtained  from  ten  different  sources 
does  not,  of  course,  comply  with  the  require- 
ments and  to  definitely  isolate  all  the  possible 
strains  entails  a  vast  amount  of  laboratory 
labour.^     The   various   strains   having   been 
identified  and  isolated  are  subcultured  on  a 
simple  veal  agar,  which  is  neutral  to  phenol- 
phthalein  and  contains  no  added  salt.    When 
the  colonies  have  matured  (twenty-four  to 
forty-eight  hours)   a   few   cubic   centimetres 
of  distilled  water  are  added  to  each  tube,  and 
the  gonococci  either  scraped  or  shaken  into 
suspension.    Autolysis  of  the  organisms  occurs 
with  great  rapidity  in  distilled  water,  but  to 
ensure  sterility  the  solution  is  exposed  to  a 
temperature  of  55°  C.  for  two  hours.     Solid 
particles  are  separated  by  means  of  the  centri- 
fuge, and  finally  by  the  Berkefeld  filter.     An 
antigen  so  prepared  is  said  to  be  permanent 
if  kept  in  a  cool  atmosphere.     \\Tien  about 
to  be  used  its  tonicity  is  raised  to  normal  by 
the  addition  of  one  part  of  9  per  cent  sodium 
chloride  solution  to  nine  parts  of  antigen. 
3.  Hcemolytic  system. — Washed  sheep  or  ox  blood 

1  Parke,  Davis  &  Co.  supply  an  antigen  which  has  so  far  given  me  more 
uniform  results  than  the  stock  antigens  of  my  own  preparation. 

WATSON. — 2    A 


354    GONORRHEA  &  ITS  COMPLICATIONS 

corpuscles  in  5  per  cent  suspension  are  used 
in  conjunction  with  the  serum  of  a  rabbit, 
which  has  been  immunised  against  the  cor- 
puscles employed.     Fresh  guinea-pig  serum 
is  the  most  active  complement. 
The   test    is    carried   out    by   American   bacterio- 
logists somewhat  differently  from  the  methods  usually 
adopted  in  this  country,  and  as  I  have  not  yet  suffi- 
cient experience  of  the  reliability  of  the  results  with 
our  method,   I  will  quote  the  description  given  by 
Sophian  and  refer  for  fuller  details  to  the  original 
article  of  Schwartz  and  McNeil  ("  American  Journal 
of  Medical  Sciences,"  May,  1911). 

"  Technic  of  the  test. — ^Titrate  the  antigen  to  deter- 
mine the  maximum  quantity  which  can  be 
used  without  inhibiting  haemolysis.  Titrate 
all  materials  before  commencing  the  test. 

Test  :  In  the  front  tubes  place  -01  cubic 
centimetre  and  -02  cubic  centimetre  serum 
respectively,  in  the  back  control  tube  place 
•02  cubic  centimetre  serum.  Complement  : 
•1  cubic  centimetre  of  10  per  cent  solution  of 
complement ;  antigen  in  maximum  quantity  ; 
one  positive  and  negative  control  each  with 
its  own  separate  control. 

Incubate  one  half-hour  in  water  bath. 
Add  1  cubic  centimetre  of  5  per  cent  sus- 
pension of   sheep  corpuscles,  '1  cubic  centi- 
metre of  anti-sheep  amboceptor,  equal  to  two 
units. 

Incubate  in  water  bath  one  hour  and  make 
readings." 
Swinburne,  from  whose  clinique  most  of  Schwartz 
and  McNeil's  cases  were  obtained,  places  great  reliance 
on  the  test  as  a  means  of  diagnosis  in  chronic  cases. 


IMMUNITY   REACTIONS  355 

Antibodies  do  not  appear  in  the  blood  until  the 
fourth  week  of  an  acute  urethritis,  and  therefore  the 
test  is  always  negative  in  a  new  infection  until  the 
expiry  of  that  period.  It  is  thus  possible  to  differen- 
tiate between  a  recurrence  and  a  fresh  attack.  Torrey 
reports  that  the  complement  fixatives  begin  to  be 
eliminated  in  the  rabbit  about  the  tenth  day  after 
completion  of  the  immunisation,  and  proceeds  rapidly 
until  the  fiftieth  day.  It  is  probable,  therefore,  that  a 
positive  reaction  will  result  in  patients  who  have 
been  free  of  gonococci  for  some  time,  possibly  two 
months,  but  the  exact  time  for  man  has  not  yet  been 
fixed. 

Cases  treated  with  vaccines  immediately  give  a 
positive  result.  This  justifies  the  use  of  vaccines 
therapeutically,  but  from  what  has  already  been  said 
it  will  be  obvious  that  either  an  autogenous  vaccine 
or  a  mixed  vaccine  containing  the  particular  offender 
must  be  injected.  The  observation  that  no  anti- 
bodies are  present  in  the  blood  during  the  first  three 
weeks  of  an  acute  gonorrhoea  suggests  that  vaccines 
should  be  begun  early  with  the  object  of  preventing 
complications  and  hastening  resolution. 

Skin  reaction. — The  intradermic  injection  of  gono- 
coccus  vaccine  excites  a  specific  skin  reaction  which 
is  of  diagnostic  value.  Speaking  in  April,  1912,  I 
said  : — ^ 

"  At  present  we  have  the  method  on  trial  at  the 
Glasgow  Lock  Hospital.  I  use  a  fine  hypodermic 
needle  and  Ricord  syringe,  and  inject  intradermically 
ten  to  twenty  millions  dead  gonococci  of  mixed  strains. 
Care  has  to  be  taken  to  avoid  hypodermic  instillation 
of  the  fluid.     The  needle  is  inserted  about  a  quarter  of 

'  Transactions  of  the  Medico-Chirurgical  Society  of  Glasgow,  12tli  April, 
1912. 


356    GONORRHCEA  &  ITS  COMPLICATIONS 

an  inch,  and  if  in  the  proper  stratum,  the  injection  only 
of  two  or  three  drops  is  possible.  As  the  fluid  pene- 
trates between  the  layers  of  the  skin  a  white  urticaria- 
like bleb  is  formed.  If  there  is,  or  has  been,  within 
an  as  yet  undetermined  period,  a  gonorrhoeal  infec- 
tion, a  specific  reaction  occurs.  An  area  of  intense 
redness,  slightly  exceeding  in  size  the  above-men- 
tioned bleb,  is  seen  within  a  few  hours.  The  reaction 
reaches  its  maximum  in  three  days  ;  but  the  area  of 
redness  continues  with  but  little  subsidence  for  some 
days  thereafter,  and  usually  begins  to  fade  about  the 
sixth  or  seventh  day,  and  slowly  dies  away  during 
the  following  week  or  ten  days. 

The  intensity  of  the  reaction  varies  with  the 
seriousness  of  the  case.  When  the  adnexa  are  in- 
volved the  skin  reaction  is  often  very  marked.  In 
very  old-standing  cases  there  is  a  modified  reaction 
suggestive  of  the  absence  of  gonococci. 

The  effect  of  the  injection  in  a  normal  individual 
is,  at  the  most,  a  slight  redness,  which  reaches  its 
maximum  within  twenty-four  to  thirty-six  hours, 
and  fades  to  a  barely  distinguishable  paleness  in  four 
to  five  days. 

The  modified  reaction  obtained  in  post-gonor- 
rhoeal  cases  is  between  the  normal  and  the  specific. 

These  are  the  conclusions  which  seem  to  be 
warranted  by  the  work  already  done,  but  much 
greater  experience  is  necessary  before  the  true  value 
of  the  reaction  can  be  estimated. 

Variations  in  different  strains  of  gonococci  prob- 
ably explain  a  percentage  of  misleading  negative 
reactions,  and  the  persistence  of  antibodies  in  the 
blood  after  all  gonococci  have  been  exterminated  may 
explain  the  occurrence  of  erroneous  positive  results. 
This  test,  therefore,  can  only  be  esteemed  as  of  cor- 
roborative value,  but  within  its  limits  its  usefulness 
is  considerable." 


IMMUNITY   REACTIONS  357 

ANTIGONOCOCCUS   SERUM 

Since  the  advent  of  vaccines  into  the  therapeutic 
arena  antigonococcus  serum  has  received  but  scant 
attention,  the  efforts  of  immunists,  perhaps  unfortu- 
nately, having  been  concentrated  on  the  effects  of 
vaccine  treatment.  The  serum  is  obtained  from 
animals  (rabbits,  goats,  sheep,  and  horses),  which 
have  been  immunised  by  injections  of  increasing 
doses  of  gonococcus  emulsions.  The  serum  is  tested 
as  to  its  gonococcus  antibody  content  by  means  of 
the  complement  deviation  test. 

Serum  treatment  is  applicable  more  particularly 
to  systemic  infections,  and  two  or  three  large  doses 
(15  to  25  cubic  centimetres)  are  required  with  24  to 
48  hour  intervals.  Little  if  any  effect  is  produced  on 
the  course  of  urethritis  by  serum  injection.  Serum 
applied  directly  to  the  infected  area,  having  given 
good  results  in  other  diseases,  has  been  tried  in 
gonococcal  infection.  Sophian  suggests  that  it  should 
be  injected  into  affected  joints  in  gonococcal  arthritis. 

I  have  tried  vaginal  injections  of  antigonococcus 
serum  in  the  vaginitis  of  children  without  apparent 
result. 

Auto-sero  therapy.- — The  withdrawal  of  fluid  from 
an  affected  joint  and  its  injection  into  the  neighbour- 
ing subcutaneous  tissue  has  been  practised  with  some 
success. 

Normal  horse  serum  and  antimeningococcus  serum 
have  also  been  tried  in  systemic  infections,  and  some 
favourable  results  have  been  recorded. 


358    GONORRHCEA  &  ITS  COMPLICATIONS 


GONOCOCCUS   VACCINE 

The  concensus  of  opinion,  judging  only  from  the 
pubhshed  articles  on  the  subject  of  gonococcus  vac- 
cine treatment,  may  be  summarised  as  follows  : — 

1.  Vaccines  have  no  effect  on  the  control  of  gono- 

coccal urethritis. 

2.  They  may  have  a  curative  action  on  systemic 

infections. 

3.  They  influence  beneficially  epididymitis,  salpin- 

gitis, prostatitis,  and  other  localised  and 
undrained  inflammations. 

Some  good  results  seem  to  have  been  procured, 
particularly  in  acute  arthritis  and  epididymitis  ;  but 
as  the  majority  of  these  cases  tend  to  spontaneous 
cure,  scepticism  has  not  been  wanting.  Indeed, 
several  papers  have  been  published  by  authors  whose 
opinions  carry  much  weight  discounting  entirely  as 
a  result  of  their  experience  the  usefulness  of  gonococ- 
cus vaccine,  and  in  addition  much  adverse  criticism  is 
current  which  is  not  recorded. 

My  own  experience  has  been  considerable,  and  it 
has  taught  me  that  vaccine  therapy,  as  at  present 
practised,  is  as  likely  to  do  harm  as  good.  There  is 
something  materially  at  fault  with  our  methods.  It 
is  true  that  profound  effects  can  be  produced  by  vac- 
cine injections,  but  these  results  must  be  so  guided 
that  they  can  be  depended  on  to  react  to  the  benefit 
of  the  patient  before  treatment  by  vaccines  can  be 
generally  acceptable.  Personally,  I  am  quite  con- 
vinced of  the  specific  power  of  gonococcus  vaccine  to 
modify  the  disease  one  way  or  the  other,  but  I  am 
equally  convinced  that  we  have  not  as  yet  worked 
out  the  data  necessary  to  enable  us  to  use  vaccine 


IMMUNITY   KEACTIONS  359 

with  sufficient  control  over  its  therapeutic  action  to 
justify  its  indiscriminate  employment. 

It  is  possible  to  put  vaccine  therapy  on  a  stable 
basis  and  to  eliminate  its  inconsistencies  and  vagaries 
only  by  a  thorough  understanding  of  the  agencies 
which  are  involved  by  our  interference  with  the 
balance,  or  rather  want  of  balance,  in  the  natural  im- 
munity mechanism,  and  there  are  still  here  dark  places 
on  which  light  needs  to  be  shed. 

Whether  we  fail  in  dosage,  in  proper  regulation  of 
the  intervals,  in  methods  of  preparation  or  adminis- 
tration, or  in  appreciating  the  conditions  for  which  it 
is  suitable,  has  still  to  be  determined.  Nevertheless, 
I  am  not  without  hope  that  future  developments  will 
place  in  our  hands  a  perfected  method  of  stimulating 
the  natural  processes  of  immunity. 


CHAPTER   XXVII 

SOCIAL  ASPECTS   OF   GONOCOCCAL  DISEASE 

Baneful  as  are  the  effects  of  gonorrhoea  on  the  indi- 
vidual, the  evil  does  not  always  end  there  :  many 
infected  persons  from  ignorance,  carelessness,  or 
viciousness  fail  to  restrain  themselves  from  infecting 
others. 

With  the  growth  of  the  science  of  public  health  and 
the  development  of  the  State  organisation  dealing 
with  it,  the  question  of  the  administrative  control  of 
venereal  disease  in  general  is  rapidly  becoming  a 
pressing  question. 

There  are  many  aspects  of  gonococcal  infection 
which  make  it  eminently  a  suitable  field  for  the 
activity  of  the  Health  Department.  It  will  be  granted 
that  it  is  a  contagious  disease  of  a  serious  nature  and 
widely  prevalent,  characteristics  which  should  bring 
it  within  the  domain  of  sanitary  control. 

Unfortunately,  past  efforts  on  the  part  of  the 
authorities  have  been  for  the  most  part  concerned 
with  the  supervision  of  prostitution,  and  the  diffi- 
culties have  proved  insuperable. 

Recently  a  wise  move  in  the  right  direction  has 
been  made  in  making  ophthalmic  neonatorum  notifi- 
able. Notification  is  a  necessary  preliminary  to  any 
real  attempt  to  control  the  spread  of  a  disease  ;  but 
the  difficulties  which  have  had  to  be  faced  in  forcing 
notification  on  the  profession  and  the  public,  in  con- 

360 


ASPECTS  OF  GONOCOCCAL  DISEASE    361 

nection  first  of  all  with  the  eruptive  fevers  and  latterly 
with  tuberculosis,  are  greatly  intensified  in  the  case 
of  venereal  disease.  The  imperative  demand  for 
secrecy  seems  at  once  to  make  this  proposal  im- 
practicable. But  the  necessity  for  action  remains, 
and  some  method  of  control  must  be  formulated  which, 
while  respecting  the  legitimate  demand  for  reticence, 
will  ensure  that  each  case  receives  efficient  treatment, 
and  that  infected  persons  will  not  with  impunity 
spread  the  disease. 

A  campaign  of  education,  free  access  to  skilled 
treatment  without  detention,  and  ultimately  con- 
fidential notification,  is  the  obvious  trend  of  events. 

It  is  contended  that  notification  would  drive  an 
increasing  number  of  patients  to  unqualified  practi- 
tioners. But  quackery,  at  least  as  it  affects  con- 
tagious disease,  is  an  anomaly  in  a  civilised  state,  and 
as  the  Legislature  has  effectively  removed  the  diseases 
at  present  notifiable  from  the  domain  of  the  charlatan, 
it  can  be  expected  to  deal  similarly  with  venereal 
disease  once  the  medical  profession  has  expressed  itself 
as  able  and  willing  to  undertake  its  share  of  the  task. 

A  special  State  medical  service  with  its  own  dis- 
pensaries and  hospitals  is  undesirable  for  the  treat- 
ment of  these  diseases.  The  nature  of  the  complaint 
could  not  in  such  case  be  hidden  from  friends  and 
relatives.  There  is  no  reason  why  the  present  general 
hospitals  and  dispensaries  should  not  cater  directly 
for  this  class  of  patient,  nor  is  there  any  reason  why 
the  private  practitioner  should  not  undertake  the 
cure  of  his  patients,  had  he  the  help  of  the  following 
legal  support  : — 

1.  All  persons  suffering  from  symptoms  of  venereal 
disease  must  report  in  person  to  a  qualified 
medical  practitioner  or  to  a  public  dispensary. 


362    GONORRHCEA  &  ITS  COMPLICATIONS 

2.  All  qualified  practitioners  will  report  each  case 
to  the  Medical  Officer  of  Health  on  a  special 
form  withholding  the  name  and  address, 
but  undertaking  responsibility  for  effective 
treatment  and  reporting  by  name  and  address 
if  the  treatment  is  not  satisfactorily  carried 
out  by  the  patient. 

The  Sanitary  Authorities  should  supply  suitable 
literature  for  presentation  to  the  patient,  and  should 
furnish  facilities  for  diagnostic  laboratory  tests. 

The  medical  profession  would  in  this  scheme  be 
receiving  from  the  State  a  privilege  and  a  recognition 
which  they  have  failed  to  do  in  the  case  of  any  other 
disease,  and  in  return  they  would  be  required  to 
undertake  the  full  responsibility  which  such  recog- 
nition merits,  that  is  to  say,  they  must  guarantee 
efficient  and  thorough  treatment. 

Any  practitioner  unwilling  to  take  in  hand  this 
work  could,  of  course,  refer  the  case  to  another. 

Many  details  of  such  a  scheme  remain  to  be  worked 
out,  but  there  is  no  obstacle  which  will  not  ultimately 
be  overcome  by  the  inevitable  march  of  progress. 

Gonorrhcea  and  marriage. — When  a  physician  is 
asked  by  a  patient,  who  has  in  the  past  suffered  from 
gonorrhoea,  whether  he  or  she  can  safely  marry,  the 
position  is  always  one  of  great  responsibility  and 
frequently  one  of  considerable  doubt.  The  conse- 
quences of  error  would  be  so  distressing  to  all  con- 
cerned that  there  is  no  need  to  labour  this  point.  But 
a  summary  of  the  steps  to  be  taken  before  giving  any 
advice  may  be  of  advantage. 

Rules  applicable  to  both  sexes  : — 
1.  The  length  of  time  which  has  elapsed  since  the 
first  infection  is  no  guide  whatever.     Cases 


ASPECTS  OF  GONOCOCCAL  DISEASE    363 

have  been  recorded  where  the  only  possible 
exposure  to  infection  was  as  remote  as  thir- 
teen years,  and  in  my  experience  I  have 
known  infectivity  to  last  up  to  nine  years 
without  reimplantation  of  the  gonococcus. 
2.  No  opinion  can  be  given  without  a  bacteriologi- 
cal examination  of  each  case,  as  the  in- 
dividual in  question  may  be  a  "  carrier  "  of 
the  gonococcus  without  appreciable  lesion. 

Method  of  examining  the  male. — The  patient  presents 
himself  for  examination  in  the  morning  as  soon  after 
rising  as  possible  and  without  having  emptied  his 
bladder.  Wlien  this  cannot  be  arranged,  he  must  at 
least  have  retained  his  urine  for  four  hours.  The 
meatus  is  inspected  for  any  signs  of  discharge.  If 
the  lips  are  found  glued  together,  they  are  separated 
and  the  discharge  which  is  retained  in  the  urethra  is 
expressed  on  to  a  sterile  slide  for  microscopic  ex- 
amination. A  fine  ball-pointed  probe  tightly  wrapped 
with  sterile  wool  is  next  inserted  into  the  urethra  as 
far  as  possible,  and,  using  the  utmost  gentleness,  is 
rotated  and  withdrawn.  A  tube  of  medium  suitable 
for  gonococcus  culture  is  inoculated  and  immediately 
transferred  to  the  incubator  at  37°  C.  The  same 
probe  is  utilised  for  the  making  of  smears  which  are 
stained  by  the  Gram  process,  and  methodically 
searched  for  gonococci  and  other  organisms. 

The  patient  now  passes  urine  into  three  glasses. 
The  first  glass  will  contain  any  formed  fragments  of 
discharge  which  have  been  lying  in  the  urethral  canal. 
The  second  glass  will  indicate  the  condition  of  the 
bladder,  and  the  last  may  contain  products  ex- 
pressed from  the  prostatic  or  ejaculatory  ducts  in 
the  final  contractions  of  micturition. 


364    GONORRHCEA  &  ITS  COMPLICATIONS 

The  presence  of  a  minute  drop  of  discharge  at  the 
meatus  or  of  shreds  in  the  urine  necessitates  explora- 
tion of  the  urethra  with  the  acorn-tipped  bougie  and 
with  the  urethroscope  to  locate  the  lesion  which  is 
present. 

The  prostate  and  seminal  vesicles  should  now  be 
massaged  and  their  secretion  examined  macroscopi- 
cally  and  microscopically. 

Finally,  both  epididymes  are  palpated  for  nodules, 
especially  in  the  regions  of  the  globus  major  and 
globus  minor. 

Should  the  complete  examination  reveal  no  evi- 
dence of  disease  and  no  subjective  symptoms  be 
complained  of,  permission  to  marry  is  warranted,  but 
in  case  of  any  doubt,  one  or  more  of  the  methods  of 
provoking  gonococcal  activity  may  be  adopted,  and 
the  skin  and  complement  deviation  reactions  em- 
ployed. 

Method  of  examining  the  female. — The  vulvar  glands 
and  crypts  as  well  as  the  urethra  are  inspected  for 
evidence  of  disease  as  indicated  by  elevated  and 
reddened  areas  from  which  pus  can  be  expressed. 
The  ducts  of  Bartholin's  glands  should  receive  par- 
ticular attention.  The  vaginal  walls  are  inspected  for 
areas  of  erosion  and  sero-purulent  discharge.  The 
cervix  is  displayed  and  its  condition  noted  with 
special  reference  to  ectropion  and  the  presence  of 
discharge.  After  cleaning  away  all  gross  discharge, 
swabs  are  taken  from  the  urethra,  cervix,  and  any 
other  suspected  locality,  culture  tubes  seeded  and 
smears  prepared.  The  uterus,  tubes,  and  ovaries  are 
palpated  bimanually.  A  specimen  of  urine  should  be 
obtained  to  complete  the  examination. 

When  a  thorough  examination  results  in  an 
entirely  negative  finding,  there  will  be  no  doubt  in 


ASPECTS  OF  GONOCOCCAL  DISEASE    365 

the  physician's  mind,  especially  when  the  systemic 
tests  are  invoked  and  reinforce  the  decision. 

Unfortunately,  what  will  astonish  the  medical 
attendant  as  these  examinations  become  more  fre- 
quent and  more  thorough,  is  the  number  of  cases  in 
which  undoubted  evidence  of  continued  disease  will 
be  disclosed,  and  treatment  called  for,  before  the 
patient  can  be  absolved  from  the  necessity  for 
delay. 

Prophylaxis. — ^Vhile  a  medical  man  might  justifi- 
ably refuse  to  give  information  which  might  in  any 
way  encourage  the  feeling  that  immorality  could  be 
indulged  in  with  impunity,  there  is  no  dubiety  about 
his  position  if  consulted  within  a  few  hours  of  ex- 
posure to  possible  infection  by  a  repentant  and 
anxious  transgressor.  The  physician  must  then  be 
in  a  position  to  impart  any  information  to  the  patient 
which  medical  science  has  at  its  disposal.  As  there 
is  now  a  well-established  and  reliable  prophylactic 
treatment,  this  book  would  be  incomplete  without  at 
least  an  outline  of  its  essential  features. 

The  scheme  owes  its  inception  to  German  and 
French  initiative,  but  has  been  worked  into  practical 
shape  by  medical  officers  in  the  American  Navy. 

The  treatment  must  be  such  as  will  include  an 
efficient  preventative  for  all  the  venereal  diseases.  The 
following  summary  may  be  accepted  as  typical  of  the 
methods  which  have  proved  successful : — 

1.  Wash  in  soap  and  water,  then   in   solution  of 

1-1000  to  1-2000  perchloride  of  mercury  for 
five  minutes. 

2.  Inject  2  to  5  cubic  centimetres  of  2  or  3  per  cent 

protargol    or  5  to  10  per  cent   argyrol    and 
retain  in  urethra  for  five  minutes. 


366    GONORRHCEA  &  ITS  COMPLICATIONS 

8.  After  drying,  massage  the  skin  of  the  glans,  pre- 
puce,   penis,    and   pubis   with   Metchnikoff's 
calomel  ointment  (33  per  cent  calomel  with 
a    base    of     equal     parts     of     lanoline    and 
vaseline). 
If  this  treatment  can  be  carried  out  in  its  entirety 
within  three  hours  of  exposure,  safety  is  almost,  if  not 
quite,  assured.    It  is  still  of  value  within  twenty-four 
hours   of   infection,    but   after   forty-eight   hours   no 
benefit  can  be  expected. 

Printed  instructions  for  dispensary  patients. — Ap- 
pended is  a  copy  of  the  slip  given  to  the  patients  at 
the  Venereal  Dispensary  of  the  Glasgow  Royal  In- 
firmary who  are  suffering  from  gonococcal  infection : — 

"  The  disease  from  which  you  are  suffering  is  con- 
tagious. 

The  infection  is  in  the  discharge  and  it  may  be 
carried  in  towels,  clothing,  sheets,  bath  water, 
water  closets,  etc. 

Your  eyes  or  the  eyes  of  others  will  become 
seriously  inflamed  if  any  of  the  poison  reaches 
them,  for  instance,  by  failing  to  wash  the  hands 
after  handling  the  parts  or  by  using  unclean  water 
for  the  face. 

You  must  therefore  be  very  careful  about  cleanli- 
ness, and  no  one  must  come  into  contact  in  any 
way  with  the  discharge. 

Avoid  all  alcoholic  drinks  and  sexual  excitement  : 
they  will  increase  the  discharge  and  pain,  and 
seriously  delay  cure. 

Continue  attending  the  dispensary  until  you  are 
told  you  are  cured,  as  the  infection  may  still  be 
there  even  after  the  discharge  has  stopped. 


ASPECTS  OF  GONOCOCCAL  DISEASE    367 

Sometimes  the  disease  becomes  chronic  although 
showing  no  symptoms.     You  should  therefore  be 
re-examined  before  marrying." 
A  similar  sheet  with  such  alterations  as  will  readily 

suggest  themselves  is  given  to  women  at  the  Lock 

Hospital. 


INDEX   OF   NAMES 


Abel,  20 

Alexander  of  Tralles,  2 

Avicenna,  3 

Aretaios,  1,  2 

Asch,  240 

Baermaim,  238,  346 

Balfour,  Francis,  5 

Bartholin,  248,  253,  271 

Bazet,  240 

Belfield,  220,  240,  243 

Bell,  Benjamin,  5 

Benique,  133 

Benzler,  233 

Bernutz,  246 

Bibergeil,   17 

Bier,  122,  236,  268,  333 

Bierhoff,  189 

Bland-Sutton,  249 

Bordet  and  Gengou,  351 

Bom,  52 

Bottcher,  188 

Brandes,  342 

Brodie,  Sir  Benjamin,  325 

Bronium,  227 

Bronnum,  14 

Bruck,  239,  349 

Bruschettini  and  Ansaldo,  29 

Buerger,   162 

Bumm,  19,  273 

Burghard,   143 

Buschke,  345 

Celsus,  2 

Charriere,  132,  136 
Cockbum,  5,  6 
Cowper,  45,  47,  69 
Crede,  316 

Darier,  318 
Demours,  310 
Desormeux,   152 
Digglemann,  327 
Doderlein,  11,  251,  286 
Duncan,  Andrew,  5 
Duval,  22 

Elhs,  5 

Elser  and  Huntoon,  350 


Felix-Ramond,  334 
Finger,  20,  52,  70,  222 
Fournier,  309 
Friedlander,  175 
FuUer,  335 
Fulton,  147 

Gaddesden,  John  of,  3 
Gibson,  Benjamin,  308 
Gilbert,  334 
Gordon,  157 
Goldschmidt,   162 
Goldzieher,  322 
Goupil,  246 
Gtiiteras,  222,  235 
Gurd,  22 
Guthrie,  310 
Guy  on,  134,  144 

Hagner,  240 

Harman,  309 

Harrison  aiid  Harold,  149 

Hasse,  310 

Heab,  309 

Heissler,  71 

Hewes,  336 

Hirschfelder,  29 

Hosford  and  James,  321 

Hunter,  John,  5,  325 

Jacobsohn  and  Pick,  15 
Jadassohn,  228 
Janet,  88,  100 
Jenner,  16 
Joly,  159 
JuUien,  222 

Keyes,  233,  328 

Kobelt,  146 

Koch,  7 

Kock  and  Preston,  152 

Kollmama,  130,  137 

Krzysztalowitsz,  15 

Lebreton,  110 
Leedham-Green,  53 
Lehr,  305 
Littre,  45 
Loefjfler,  14 


369 


370 


INDEX   OF   NAMES 


Lofaro,  337 

Low  and  Oppenheim,  227 

Luys,  148,  155 

Maimon,  3 

Martin,  242 

Martin,  W.  B.  M.,  21,  327,  350 

Mayerne,  Tourquet  de,  6 

Menge,  257 

Metchnikoff,  366 

Miles,  112 

Morgagni,  6,  145 

Muir,  17 

Miiller  and  Oppenheim,  349,  351 

Murrell,  325 

Neisser,  6,  7,  97,  222 
Nicoll,  134 
Nitze,  152 
Noeggerath,  246 

Oberlaender,  130 
Osier,  328 

Pappenheim,  15 

Paracelsus,  4 

Parnell,  272 

Paul  of  Aegina,  3 

Perigoff,  238 

Pick  and  Jacobsohn,   14 

Piringer,  309 

Plato,  18 

Pollmann,  148 

Pollock  and  Harrison,  326 

Pott,  285 

Proksch,  2 

Quellmatz,  310 
Queyrat,  334 

Ricord,  1,  4,  6,  342 
Robert,  346 
Rollet,  222 
Roux,  16 

Salicet,  Guillaume  de,  3 
Schaffer,  15 
Scharrf,  147 
Schindler,  107,  149,  227 


Scholtz,  12L  302 
Schwartz  and  McNeil.  351 
Sequiera  and  Turnbull,  346 
Simpson,  347 
Skene,  247.  254,  272 
Skutsch,  285 
Smith,  Henry,  238 
Sophian,  354,  357 
Stephenson,  249 
Stephenson,  Sydney,  310,  317 
Swinburne,  354 

Tarnousky,  222 

Teague  and  Torrey,   351,  353 

Thalmann,  28 

Thayer  and  Blumer,  342 

Thompson,  59,  74 

Tode,  I.  C,  5 

Torrey,  350,  355 

Turro,  29 

Tyson,  178 

TJhma,  17 

Unna-Pappenheim,   19 
Ultzmann,  144 

Valentine,  152 
Valescus,  3 
Vannod,  30,  349,  350 
Velpean,  238 
Vidal,  346 

Waelsch,  189 
Wahl,  15 
Waldeyer,  250 
Wassermann,  349,  351 
Weeks,  309 
Weigert,  7,  16 
Wertheim,  7,  19,  274 
West,  246 
Winkler,  F.,  17 
Wiseman,  4 
Wossidlo,  162 
Wyndham-Powell,  96,   154 

Young,  249 

Zweifel,  251 


INDEX 


Abel's  blood  agar,  20 
Abortive  treatment,  107 
Abscess  of  Bartholin's  glands,  271 

—  of  Cowper's  glands,  67 

—  of  inguinal  glands,  59,  66 

—  of  prostate,   199 

—  urethral,  37 

—  of  vesicula  seminalis,  218 
Acorn-tipped  bougies,  131 
Adenitis,  59,  66 

Agar,  Gurd's,  22 

—  Hirschfelder's,  29 

—  Martin's,  21 

—  Thalmann's,  28 

—  Watson's,  27 
Agglutination,  350 
Albargin,  97,  105 
Albuminuria,  74 
Alcohol,  SI 

Anaesthetics,  urethral,  93,  104 
Anatomy  of  epididymis,  224 

—  of  female  genital  tract,  247,  286 

—  of  male  urethra,  43 

—  of  prepuce  and  glans,  177 

—  of  prostate,  184 

—  of  vesicalse  seminalis,   213 

—  of  vulva  and  vagina  in  children, 
286 

Anterior  iirethra,  capacity  of,  54 

—  urethritis  (see  Urethritis) 
Antibodies,  35,  65,  355 
Antigen,  gonococcal,  352 
Antigonococcus  serum,  357 
Antiseptics,  urinary,  82,  85,  273 
Aortitis,  342 

Applicator,  uterine,  279 

Ardor  urinse,  60 

Argentide,  98 

Argyrol,  97 

Ascites  fluid  in  media,  19 

Assurance  of  cure  in  female,  269,  364 

in  male,  363 

Atropine,  107,  109,  113,  114,  139 
Auto-sero  therapy,  334,  357 

Bacilli,  anaerobic,  12 
Bacillus  Bulgaricus,  264 

—  of  Doderlein,  11,  251,  286 
Bactericidal  action  of  sera,  350 


Bacteriology  of  balanitis,  178 

—  of  gonorrhoea,  7 

—  of  urethritis  simplex,  174 

—  of  vagina,  11 
Bacteriuria,  76 
Balanitis,  66,  177 

—  chronic,  181 
Balsamics,  82,  86 
Bartholin's  glands,  248 

abscess  of,  271 

infection  of,  253 

Belfield's  operation,  243 
Benique  scale,  133 

Bier  treatment  of  cervix,  268 

—  — -of  epididymitis,  236 

of  rheiimatism,  333 

of  urethritis,  112 

Bleeding  after  dilatation,  136 
Blood  agar,  20 

—  human,  for  media,  23 
Blood-vessels,    gonococcal    infection 

of,  342 
Bordet-Gengou  reaction,  351 
Boric  acid,  85,  86 
Bottcher's  crystals,  188 
Bougies,  acorn,  131 

—  dilating,  129 

—  flexible,  131 

—  heated.   111,   146 

—  soluble,  medicated,  54,  112,  149 
Bubo,  59,  66 

Bubonulus,  66 

Buchu,  82 

Buerger's  cysto-urethroscope,  162 

Bm-ghard's  urethral  knives,   143 

Camphor  monobromate,   80 
Capacity  of  anterior  urethra,  54 
Carriers  of  gonococci,  42,  64,  108 
Casts,  urethral,  67 
Catarrhal  prostatitis,  191 
Cauterization,  141 
Cervix,  infection  of,  252 

—  treatment,  263 

—  of  child,  286 

—  mucous  membrane'  of,  248 

—  smear  from,  9 
Charriore  scale,  132 

Children,  female  infection  of,  285 


371 


372 


INDEX 


Chordee,  67 

—  treatment  of,  80 
Choroiditis,  324 
Cocaine,  93 

Colliculus  seminalis,  47 
Complement  deviation,  351 
Complicated  gonorrhoea,  118 

in  female,  271 

Compressor  urethrse,  51,  54 
Condylomata  aciuninata,  66,  171,  294 
in  pregnancy,  283 

treatment  of,  297 

Conjunctivitis    in    infants   (see  Oph- 
thalmia neonatorum) 

—  gonococcal  in  adults,  320 

—  metastatic,  323 
Copaiba,  82,  83 

Cornea,  disease  of,  313,  315,  320,  321 
Cowper's  glands,  45,  47 

inflammation  of,  69 

Crista  urethrse,  47 

Cubebs,  82,  84 

Cultivation  of  gonococcus,  19 

Culture  media,  19 

Curetting  endometrium,  276 

—  male  lurethra,  144 
Cutaneous  reaction,  355 
Cystitis,  gonococcal,  245,  272,  301 

in  the  female,  254,  272 

treatment  of,  302 

Cysts,  urethral,  37,  67,  171 

Deferenitis,  228 

Degenerated  gonococci,  8,  17,  30 

Deviation  of  complement,  351 

Diet,  81 

Dilatation,  129 

Dilating  sounds,  130 

Dilators,  Kollmann's,  137 

Diphtheria  of  vulva,  286 

Diphtheroid  bacillus,  179 

—  membrane,  67 
Diplobacillus  vaginte,   12 
Direct  infection  of  the  female,  255 

of  the  male,  39 

Distribution    of    gonococci    in    male 

urethra,  55 
Doderlein's  bacillus,  11,  251,  286 
Duval's  medium,  22 

Ectropion,  59,  65 
Ejaculatory  duct,  225 
Electrically  heated  bougies.  111 
Electrode,  urethral,  148 
Electrolysis,  140 
Emissions,  73,  80,  114 
Endarteritis,  34,  342 
Endocarditis,  342 
Endometritis,  acute  gonococcal,  273 

symptoms  of,  275 

treatnaent  of,  275 


Endometritis,  chronic,  276 
• treatment  of,  276 

—  subacute,  276 
Endotoxin,  gonococcal,  352 
Epididymitis,  222 

—  anatomy  of,  224 

—  treatment  of,  233  ^ 

operative,  238 

Epididymotomy,  240 
Epididymo-vasotomy,  242 
Erections,  painful,  60,  73 

treatment  of,  80 

Erythema,  gonococcal,  345 
Eucaine,  93,  104 
Exacerbations,  incubation  of,  42 
Extracellular  gonococci,   10,  34 
Extra-venereal   infection    of   female, 

256 

of  male,  40 

Eye,  gonococcal  disease  of,  308 

Fallopian  tubes,  250 

infection  of,  279 

Female,  gonorrhoea  in,  245 

complications,  271 

symptoms  of,  251 

treatment  of,  261 

Filaments,  lu-inary,  13,  123,  125,  197 

Fissures,  urethral,  171 

Fistula,  urethral,  70 

Fixation  of  complement,  351 

Fluid  culture  media,  20,  29 

Follicular  prostatitis,  191 

Fossa  navictilaris,  43 

Friedlander's  bacillus,  175 

Funictilitis,  228 

Furnishing  of  treatment  room,  102 

Galvano- cautery,  142 

Gauge,  English  and  French,  132 

Glands  of  Bartholin,  248,  253 

—  of  Cowper,  45,  47,  69 

—  of  Littre,  45 
Glans,  anatomy  of,  177 

—  infection  of,  177 
Goggles,  protective,  313 
Goldschmidt's  urethroscope,  162 
Gonococcal     affections     of     vascular 

system,  342 
Gonococcal  infection  of  the  eye,  308 

of  Fallopian  tubes,  279 

of  kidney,  304 

of  placenta,  283 

■ in  pregnancy,  282 

prophylaxis  of,  365 

in  the  puerperium,  284 

of  uterine  adnexa,  273 

—  inflammation,  pathology  of,  33 

—  skin  disease,  355 
Gonococcus  carriers,  42,  64,  108 
— •  colonies,  25 


INDEX 


373 


Gonococcus,  cultivation  of,  19 

—  degenerated,  8,  17,  30 

—  discovery  of,  7 

—  distribution  of,  in  male  urethra,  55 

—  from  vu-ine,  30 

—  luicroscopic  appearance  of,  7 

—  plating  of,  19,  22 

—  search  for  (see  Smear) 

—  septicsemia,  336 

—  size  of,  8 

—  staining  of,  8 
in  sections,  18 

—  stimiilation  of,  13,  121,  269 

—  vaccine,  358 

—  \'ital  colouring  of,  17 
Gonorrhoea,  complicated,  118 

—  history  of,  1 

—  social  aspects  of,  360 
Gordon's  urethroscope,  157 
Gram's  stain,  9,  16 

Grand  lavage  (see  Lavation) 
Gurd's  agar,  22 
Guyon's  scale,  134 

—  sjTinge,  144 

Haematuria,  terminal,  73,  114 
Heart,  gonococcal  infection  of,  342 
Heat  in  treatment.  111,  144 

of  ophthalmia,  322 

Hexamethylen-tetramine,  85,  139 

Hirschfelder's  agar,  29 

History  of  gonorrhoea,  1 

Hydrocele  fluid,  19 

Hj'peracute  anterior  urethritis,  65 

Hj^erkeratosis,  346 

Ichthargan,  98 
Immiuiity,  40,  116 

—  reactions,  349 
Incision,  143 
Incubation,  period  of,  41 
Indirect  infection  of  female,  256 

of  male,  40 

Infiltrations,  168 

—  diagnosis  of,  123,  131 

—  dilatation  treatment  of,   130 

—  hard,  169 

—  soft,  168 

—  of  posterior  ruethra,  172 
— -  pathology  of,  36 
Influenza  bacillus,  175 
Injection  treatment,  89,   128 

—  solutions,  93 
Instillations,  144 
Intracellular  gonococci,  11,  34,  61 
Ionization,  147 

Iritis,  323 
Irrigation,  104,  128 

Jacobsohn  and  Pick's  stain,  15 
Jenner's  stain,  16 


Joly's  urethroscope,   159 

Kava-kava,  82,  85 
Keratodermia  blenorrhagica,  346 

treatment  of,  347 

Kidney,  gonococcal  infection  of,  304 
Kobelt  bougies,  146 
Kolhnann's  dilators,  130,  137 
Krzysztalowitsz  stain,  15 

Lactic  acid  bacillus,  264 

pessaries,  265,  293 

content  of  vagina,  11,  251 

in    treatment    of    condylomata 

acLuninata,  298 

swabbing,  265 

Lacunte,  45,  67 

Largin,  97 

Lavage  (see  Lavation) 

Lavation,  88,  100,  114,  128 

—  abortive,  110 

—  solutions  for,  104 
Littre,  glands  of,  45 
Loeffler's  stain,  14 
Luys's  urethroscope,  155 
Lymphangitis,  34,  59,  66 

Marriage    and    chronic    gonorrhoea, 

212,  255,  362 
Massage  of  prostate,  210,  214 

—  in  rheiunatism,  334 

—  of  urethra,  122 

—  of  vesicula  seminalis,  220 
Meatatomy,  137 

Media,  fluid,  20,  29 

• —  Bruschettini  and  Ansaldo's,  29 

—  Gurd's,  22 

—  Hirschfelder's,  29 

—  Martin's,  21 

—  reaction  of,  20,  27 

—  Thalmann's,  28 

—  Vannod's,  30 

—  Watson's,  27 

—  Wertheim's,  19 
Medicated  bougies,  54,  112,  149 
Membranous  urethra,  46 
Meningococcus,  13 
Metastasis,  70 

Methylene  blue,  82,  85 

Micrococcus  catarrhalis,  13,  64,  175, 

350 
Mixed  infections,  257 
Morgagni,  lacimse  of,  45 
Mucus  in  Tirme,  76 
Musculature  of  urethra,  51 
Myocarditis,  342 

Nargol,  98 

Neurasthenia,  sexual,  208 
Night  injections,  92 
Notification  of  gonorrhoea,  360 


374 


INDEX 


Novargan,  97 

Ointments,  149 
Oleum  santali,  84 
Ophthalmia  neonatoriim,  309 

incidence  of,  311 

incubation  of,  312 

prophylaxis  of,  315 

symptoms  of,  313  ■ 

treatment  of,  316 

Opsonic  action,  350 

Ovaries,  infection  of,  279 

Oxalic  acid,  105 

Oxycyanide  of  merciu"y,  110,  111,  130 

Papillomata,  171,  172 

—  treatment  of,  142 
Pappenheim's  stain,  15 
Papyrus  Ebers,  2 
Paraphimosis,  59,  66,  177,  180 

—  treatment  of,  181 
Para-urethral  passages,  68 

in  female,  252,  271 

Parenchymatous  prostatitis,  191 
Parnell's  speculum,  272 
Pathological  histology  of  gonorrhcsa, 

33 
Pericarditis,  342,  344 
Peritonitis,  gonococcal,  279 
Pessaries  of  lactic  acid  bacilli,   265, 

293 
Phagocytosis,  34,  62 
Phimosis,  59,  66,  177,  180 
Phlebitis,  34,  342,  344 
Phosphaturia,  76,  81,  125 
Pick  and  Jacobsohn's  stain,  14 
Placenta,  infection  of,  283 
Pneumococcus,  175 

—  in  conjimctivitis,  309 

—  in  vulvo-vaginitis,  285 
Pollmann's  electrode,  148 
Pollutions  (see  Emissions) 
Polyuria,  209 

Posterior  urethritis  (see  Urethritis) 

Post-gonorrhoeal  lesions,  117 

Posthitis,  66,  177 

Potassium  permanganate,  93,  104 

Precipitins,  350 

Pregnancy  and  gonorrhoea,  282 

Prepuce,  anatomy  of,  177 

Preputial  sac,  bacteriology  of,  178 

Prophylaxis,  78,  365 

Prostate,  abscess  of,  199 

—  anatomy  of,  184 

—  examination  of,  190 

—  physiology  of,  187 

—  secretion  of,  188,  197,  207 
Prostatic  utricle  (see  Sinus  pocularis) 
Prostatitis,  184 

—  classification  of,  191 

—  treatment  of,  198 


Prostatitis,  chronic,  205 

treatment  of,  210 

Protargol,  96 

Protracted  gonorrhoea,  118 

Provocative  tests,  13,  121 

in  female,  269 

Puerperium,  infection  during,  284 
Pyelitis,  gonococcal,  305 
Pyelo-nephritis,  307 

Reaction  of  mediimi,  20,  27 
Pvectal  douche,  113,  198 

—  examination,  69,  74,  206 
Relapses,  63,  118 
Retention  of  urine,  65,  113,  199 
Rheumatism,  gonorrhoeal,  325 

classification  of,  328 

symptoms  of,  329 

treatment  of,  333 

Salicylates,  85 

Salol,  85 

Salpingitis,  gonococcal,  279 

symptoms  of,  280 

treatment  of,  281 

Sandal-wood  oil,  82,  84 
Schaffer's  stain,  15 
Schindler's  agar  jelly,  149 
Section  staining,  18 
Seminal  emissions,  73,  80,  114 

—  vesicles,  213 
Septicsemia,  gonococcal,  336 

symptoms  of,  338 

treatment  of,  340 

Serum,  antigonococcus,  357 

—  antimeningococcus,  357 

—  normal  horse,  357 

—  solidified,  7 

Sexual  neurasthenia,  208 

Silver  nitrate,  95 

Sinus  pocularis,  49,  73,  77,  113,  125, 

143,  166,  172 
Sitz  baths,  79,  113,  299 
Skene's  ducts,  247 

infection  of,  254,  272 

Skin,  gonococcal  disease  of,  345 

—  reaction  to  vaccines,  355 
Smear,  preparation  of,  from  the  male, 

8,  58,  121 
from  the  female,  9 

—  from  the  female  child,  288 

—  microscopic  appearance  of,  10,  61 

—  staining  of,  9 
Smegma  bacillus,  179 

Social  aspects  of  gonococcal  disease, 

360 
Sodiiun  bisulphite,  105 
Sounds,  dilating,  130 
Speculimi  for  female  urethra,  272 

—  for  uterus,  278 
Spermatic  crystals,  188 


INDEX 


375 


Spermato-cystitis,  213 

Sphincters  of  posterior  urethra,  51 

Stovaine,  100 

Strangi-iry,  72 

Stricture   (see  also  Infiltrations),  36, 

70 
Suction  action  of  urethra,  39,  56 
Suspensory  bandages,  4,  80,  234 
Syringe,  large,  105 

—  small,  89 

Temperatux'e  for  gonococcal  growth, 

24,  26 
Terminal  hcematm-ia,  73,  114 
Thalmann's  agar,  28 
Thermo-therapy,  111,  144 
Thompson's  two  glass  test,  59,  74 
Three  glass  test,  74,  196 
Tyson's  glands,  178 

Ultzmann  syringe,  144 
Unicist  doctrine,  5 
Unna-Pappenheim  stain,  19 
Urates,  76 

Urethra,  anatomy  of  male,  42 
of  female,  247 

—  bacteriology  of,  10 

—  smear  from,  8,  9 

Urethritis,     abortive    treatment    of, 
107,  145 

—  acute,  39 
anterior,  57 

internal  treatment  of,  82 

local  treatment  of,  87 

posterior,  70 

treatment  of,  112 

—  chronic,  116 

pathology  of,  35 

treatment  of,  127 

—  in  the  female,  253 
treatment  of,  263 

—  hyperacute,  65 

—  simplex,  173 

—  subacute,  63 
Uretliroscope,  151 

—  Buerger's,  162 

—  Goldschmidt's,  162 

—  Gordon's,  157 

—  Joly's,  159 

—  Luys's,  155 

—  Wossidlo's,  162 

—  Wyndham-Po  well's,  154 
Urethroscopic  appearance  of  diseased 

urethra,  167 


Urethroscopic  appearance  of  normal 

urethra,  164 
Urethroscopy,  technique  of,  168 
Urinary  antiseptics,  82,  85,  273 
Urine  agar,  20 

—  filaments  in,  13,  123,  125,  197 

—  gonococcus  in,  13,  30 

—  retention  of,  65,  113,  199 

—  separate  glass  tests,  74,  124 
Urotropine,  85 

Urticaria,  gonorrhoeal,  345 
Uterine  applicator,  278 

—  mucous  membrane,  248 
infection  of,  273 

—  secretion,  250 

—  speculum,  278 
Uvse  ursi,  86 

Vaccine,  gonococcus,  293,  358 
Vagina,  bacteriology  of,  11 

—  of  child,  286 

—  lymphatics  of,  250 

—  mucous  membrane  of,  248 

—  secretion  of,  250 

—  treatment  of,  264 
Vagmal  bacillus,  12,  251,  286  ' 
Vas  deferens,  225 

Venereal    warts     (see     Condylomata 

acuminata) 
Verumontanum,  47,  143,  167,  172 
Vesiculse  seminales,  213 

examination  of,  216 

massage  of,  220 

physiology  of,  215 

Vesiculitis,  213 

—  acute,  217 

—  chronic,  218 

—  pathology  of,  216 
Vital  colouring,  17 

Vulva,  mucous  membrane  of,  248 
Vulvitis,  252 

—  treatment  of,  262 
Vulvo-vaginitis  in  children,  285 

—  complications  of,  289 

—  symptoms  of,  287 

—  treatment  of,  290 

Wahl's  stain,  15 

Warts,    venereal    (see    Condylomata 

acuminata) 
Weeks's  bacillus,  309 
Wossidlo's  urethroscope,  162 
Wyndham-Powell's  urethroscope,  1 54 


Henry  Kimpton,  203  High  Holboin,  London,  W.C. 


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